Health inspection·October 25, 2021

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 and interview the facility failed to ensure Resident #47 had the right to make choices about aspects of his/her life in the facility, including a change in rooms, that was significant to the resident. This affected one resident (#47) of two residents reviewed for choices. Findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 on a Minimum Data Set (MDS) 3.0 assessment, dated 09/03/21, indicating the resident had moderately impaired cognition. However, there was no documentation in the resident's medical record the resident was unable to make decisions for herself. Review of a social service progress note, written by Social Service Aide #635 on 10/01/21 at 4:25 P.M. revealed Resident #47 was requesting to be moved with her friend across the hall. The note indicated the resident was advised she would be moved on Saturday when housekeeping staff returned. Review of a social service progress note, dated 10/01/21 at 4:27 P.M. revealed Resident #70 requested to have her friend across the hall as her roommate. She understands the move would happen on Saturday when housekeeping staff returned. On 10/18/21 at 10:41 A.M. interview with Resident #47 revealed she had wanted to change rooms and move across the hallway into a room with her friend. She stated the facility spoke with her son, who was her power of attorney and since he did not want her to move, she was not permitted to change rooms. The resident stated she wanted to make her own decisions. Interview with Social Service Aide (SSA) #635 on 10/20/21 at 3:15 P.M. confirmed she documented the notes indicating Resident #47 and #70 were notified Resident #47 would be moving into the room with Resident #70. She stated the room move did not occur because the healthcare team did not feel it would be ideal for them to be roommates and Resident #47's son did not want her to be moved. SSA #635 indicated the surveyor should discuss this further with the Interim Director of Nursing because she really only documented on the room move and was not involved with the decision not to move the resident. Interview with Interim Director of Nursing #325 on 10/20/21 at 3:20 P.M. revealed she did not know why Resident #47 was not moved to the room with her friend after she was told she would be moved. A copy of an email was provided to the surveyor which was sent from Environmental Services Director Page 1 of 36 365620 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0561 Level of Harm - Minimal harm or potential for actual harm #100 to a group of staff including the Administrator, Social Service Aide #635, and Social Service Coordinator #860 which documented Resident #47's room was not changed because her son said no. There was no additional information provided to support the resident not being able to make this choice for herself or any follow up discussion regarding the resident's request. Residents Affected - Few 365620 Page 2 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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. Based on record review, interview and facility policy and procedure review the facility failed to notify Resident #15's family of a change in condition and new medication orders. This affected one resident (#15) of one reviewed for change in condition. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. A physician's order, dated 04/21/21 revealed the resident was admitted to Hospice services. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. Review of the mood and behavior section of the MDS revealed the resident displayed verbal behaviors directed towards others, behaviors not directed towards others and wandered. The resident required supervision with bed mobility, transfers and ambulation. The MDS indicated the resident had less than six months life expectancy and received Hospice services. Review of the resident's monthly physician's orders for October 2021 revealed an order, dated 10/18/21 for oxygen at two liters per minute as needed for shortness of breath and an order for the antibiotic, Cefuroxime Axetil 500 milligrams (mg) by mouth one time daily for one day then give one tablet by mouth twice a day for four days for probable lower respiratory infection. Review of the medical record failed to provide any documented evidence of why the resident was placed on an antibiotic or evidence the resident's son was notified of the change in condition or new orders. On 10/19/21 at 9:27 A.M. a family interview conducted with Resident #15's son revealed he was not aware of any recent respiratory infections or recent medication changes for the resident. On 10/20/21 at 3:10 P.M. interview with Interim Director of Nursing (IDON) #235 verified the resident's son was not notified of the change in condition or new medication orders dated 10/18/21. Review of the facility policy titled, Change in Condition, dated 11/2016 revealed the facility must immediately inform the resident, consult with the resident's physician and notify the resident representative when there was a significant change or a need to alter treatment significantly. 365620 Page 3 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were complete and accurate. This affected two residents (#25 and #54) of 27 sampled residents whose MDS assessments were reviewed. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 04/03/19 with diagnosis including mood disorder, depression and dementia with behavioral disturbance. Review of the physician's orders for 07/2021, 08/2021, 09/2021 and 10/2021 revealed Resident #25 was not receiving any medications for mood disorder, depression or behavioral disturbances. Review of Resident #25's quarterly MDS 3.0 assessment, dated 08/04/21 revealed the cognitive patterns, mood and behavior section of the assessment were incomplete. The answer boxes contained dashes for the interviewer and staff portion of the assessment. Review of the progress notes for the look back period of the quarterly assessment did not reveal any abnormal behaviors noted. Review of Resident #25's plan of care revealed a plan in place to address resisting care, refusal of care and inappropriate sexual behaviors. On 10/20/21 at 10:20 A.M. interview with Social Service Aide (SSA) #400 revealed she completed the sections for cognitive patterns, mood and behavior of the MDS. SSA #400 revealed she would insert dashes for the answer if the resident was discharged to the hospital before the assessment was completed, if the resident was non verbal or if the resident was in a vegetative state. SSA #400 confirmed she completed the MDS sections for cognitive patterns, mood, and behaviors for Resident #25 and had inserted dashes for the answers but stated this was because the resident refused to answer the questions. She also confirmed the staff assessment portion was not completed. 2. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting and dressing and to require supervision with two person physical assist for eating and drinking. On 10/18/21 at 12:04 P.M. observation of the lunch meal revealed Resident #54's meal tray was set up by staff and the resident was observed to be feeding herself independently with staff supervision. Interview with Registered Nurse (RN) #325 on 10/20/21 at 3:15 PM verified Resident #54 was able to eat independently with supervision and set up from one staff member and the MDS assessment dated [DATE] was incorrect. 365620 Page 4 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, review of pre-admission screening review results and interview the facility failed to ensure Resident #67, a resident with a newly evident mental disorder was referred to the appropriate State-designated mental health authority for review for the need for level two services. This affected one resident (#67) of one resident reviewed for pre-admission screening and resident review (PASARR). Findings include: Medical record review revealed Resident #67 was admitted to the facility 02/25/20. Review of a pre-admission screening review, dated 02/25/20 revealed the resident had no indications of serious mental illness. Therefore, an in-person assessment was not required. A diagnosis of psychosis was added for the resident on 10/28/20. Review of nursing progress notes revealed on 10/26/20 at 3:28 P.M. Resident #67 had several behaviors on this date. The resident has been verbally aggressive towards staff. Resident has called family members making up stories on staff. Resident has yelled and screamed at this nurse and aide all day making negative comments and refusing care. Physician notified and received new order to give an extra one time dose of Ativan at 5:30 P.M. and change Ativan order to one milligram three times daily. A note on 10/27/21 at 1:47 A.M. revealed the resident was having increased agitation this shift. Yelling out for staff, refusing to use the call light and calling facility. Redirection ineffective. A note on 10/28/20 at 10:35 P.M. revealed resident had a very rough day. Resident has been yelling and screaming non stop all day at residents and staff. Resident has made several calls to family members and making up things that are not true. The family members have called back and spoke to this nurse stating they know the things she is saying are not true and are on our side but they want to know if she could possibly start some new and stronger medications for all these behaviors and lies she is calling them about daily. This nurse and aides have tried anything and everything to please her today and get her anything she needed or wanted but the resident wanted to cuss, scream, and was combative, argumentative, and disagreeable to nurses and aides today. A note on 10/29/20 at 8:15 A.M. revealed staff spoke with physician about resident's recent behaviors. New order was given for an antipsychotic (Risperdal 0.5 milligrams twice daily) for psychosis. Review of Minimum Data Set (MDS) 3.0 assessments, dated 10/30/20, 12/04/20, 03/04/21, 06/17/21, and 09/17/21 all indicated the resident had a psychotic disorder. The annual MDS 3.0 assessment, dated 03/04/21 indicated a level two review was not done. There was no evidence Resident #67, who had a newly evident mental disorder, was referred to the appropriate State-designated mental health authority for review for the need for level two services following the new diagnosis. On 10/19/21 at 8:40 A.M. interview with Interim Director of Nursing (DON) #325 confirmed the last 365620 Page 5 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0644 Level of Harm - Minimal harm or potential for actual harm resident review by the State authority was on 02/25/20 (at the time of the resident's admission). The Interim DON confirmed the resident was not referred to the State-designated mental health authority for review for the need for level two services after the new diagnosis of psychosis on 10/28/20. Residents Affected - Few 365620 Page 6 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on obsesrvation, record review, interview and facility policy and procedure review the facility failed ensure baseline care plans for Resident #61 and Resident #226 included the use of oxygen. This affected two residents (#61 and #226) of 27 sampled residents whose care plans were reviewed. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's admission Evaluation dated 09/10/21 revealed the resident was admitted with no special treatment and/or procedure. The resident had no baseline plan of care related to oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The resident required extensive assistance of two staff for bed mobility, transfers and was dependent on two staff for bathing. The assessment indicated the resident had no natural teeth or fragments. The assessment revealed the resident received oxygen therapy. Review of the resident's progress notes revealed on 09/19/21, 09/20/21, 09/21/21, 09/22/21, 09/23/21, 09/24/21, 09/25/21, 09/26/21, 09/27/21, 09/28/21, 09/29/21, 09/30/21, 10/01/21, 10/02/21, 10/03/21, 10/04/21, 10/05/21, 10/10/21 and 10/12/21 the resident had received oxygen therapy. On 10/18/21 at 3:46 P.M. observation of the resident's room revealed an oxygen concentrator with undated oxygen tubing wrapped around the handle of the resident's night stand. On 10/20/21 at 10:45 A.M. interview with Interim Director of Nursing (IDON) #235 verified the resident utilized oxygen, had no order physician order for the oxygen and the baseline and/or comprehensive plan of care did not reflect the need for/use of oxygen for the resident. 2. Review of Resident #226's medical record revealed an admission dated of 10/13/21 with the admitting diagnoses of pneumonia due to COVID-19, symbolic dysfunction, hypertension, gastro-esophageal reflux disease, hypothyroidism, anxiety disorder and major depressive disorder. Review of the resident's discharge instructions from the acute care hospital stay revealed the resident's oxygen use had peaked at 11 liters but the resident now required oxygen at 3 to 5 liters per minute via nasal cannula to maintain oxygen saturations. Review of the resident's admission evaluation dated 10/13/21 identified the resident as having no special treatments/procedures for respiratory status. The resident had no baseline plan of care related to the resident's oxygen use. Review of the plan of care, dated 10/15/21 revealed the resident was at risk and/or has a 365620 Page 7 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respiratory impairment. Interventions included obtain pulse oximetry and report abnormal findings, administer medications/treatments as ordered per physician, elevate the head of the bed and evaluate lung sound and vital signs as needed. Review of the resident's monthly physician's orders for October 2021 identified no orders for oxygen or pulse oximetry. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment with assessment reference date (ARD) of 10/20/21 was still in progress at the time of the survey. On 10/18/21 at 11:15 A.M. Resident #226 was observed with oxygen at two liters per minute per nasal cannula. On 10/19/21 at 1:57 P.M. interview with IDON #235 verified the resident had no plan of care for the roxygen use. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content, dated 01/31/17 revealed upon admission, a care plan was developed to address the primary reason for admission and treatment of the resident's most immediate care needs. A comprehensive care plan was developed within seven days of completion of the comprehensive assessment. 365620 Page 8 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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. Based on observation, record review, staff interview and facility policy and procedure review the facility failed to develop a comprehensive plan of care related to oxygen use for Resident #15. This affected one resident (#15) of 27 sampled residents whose care plans were reviewed. Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The resident required supervision with bed mobility, transfers and ambulation. The MDS indicated the resident had less than six months life expectancy and received Hospice services. Review of the resident's plan of care revealed no care plan addressing the resident's respiratory status and oxygen use. On 10/19/21 at 2:20 P.M. observation of the resident's oxygen concentrator revealed it was powered on and set at two liters per minute. The resident's oxygen tubing was laying on the floor while the resident was sitting on her bed. On 10/20/21 at 3:10 P.M. interview with Interim Director of Nursing (IDON) #235 verified the resident had no comprehensive plan of care addressing the oxygen use. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content, dated 01/31/17 revealed upon admission, a care plan was developed to address the primary reason for admission and treatment of the resident's most immediate care needs. A comprehensive care plan was developed within seven days of completion of the comprehensive assessment. 365620 Page 9 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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. Based on record review and interview the facility failed to revise Resident #17's plan of care related to range of motion following the discontinuation of therapy services. This affected one resident (#17) of 27 sampled residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/15/21. The resident was admitted from the hospital after treatment for a cerebral vascular accident. Review of an admission Minimum Data Set (MDS) 3.0 assessment, dated 04/22/21 revealed the resident had short and long term memory impairment, required extensive assistance from two staff with transfers, locomotion, dressing and hygiene. The resident required extensive assistance from one staff for eating. The resident was identified as having impairment in range of motion of the upper and lower extremities on one side. Record review revealed the resident was provided with physical therapy from 04/16/21 until 06/24/21. The physical therapy evaluation revealed the resident was exhibiting a new onset of decrease in functional mobility. Notes indicated the resident previously lived in an apartment independently. The notes indicated the resident's left lower extremity range of motion was impaired but without contractures. The physical therapy discharge summary on 06/24/21 revealed the resident required substantial/maximal assistance with transfers from chair to bed, was dependent for toilet transfer and no longer allowed attempts at walking. The discharge summary revealed follow up care was to include a restorative range of motion program. There was no evidence a restorative range of motion program was implemented. Review of Resident #17's plan of care (initiated 04/16/21) revealed the resident had an activity of daily living deficit as evidenced by muscle atrophy and weakness multiple sites related to recent cerebral vascular accident. The goal was to improve activity of daily living self performance. The only intervention included was physical therapy (which was discontinued 06/24/21). There was no evidence the plan of care was revised after therapy was discontinued 06/24/21. Review of a quarterly MDS 3.0 assessment, dated 07/23/21 revealed the resident was totally dependent upon two staff for transfers, required extensive assistance from staff with dressing, eating, and hygiene, and now had impairments in range of motion on both sides including upper and lower extremities. Interview with MDS Coordinator #145 on 10/20/21 at 11:09 A.M. confirmed there was no evidence the plan of care was revised related to range of motion after therapy was discontinued 06/24/21. 365620 Page 10 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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 observation, record review and interview the facility failed to ensure Resident #48 and Resident #61, who required extensive assistance/dependence on staff for activities of daily living received adequate and routine showers to maintain proper hygiene. This affected two residents (#48 and #61) of two residents reviewed for activities of daily living. Residents Affected - Few Findings include: 1. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the plan of care, dated 09/13/21 revealed the resident had a self-care deficit as evidenced by weakness and limited mobility related to physical limitations due to a femur fracture with surgical repair. Interventions included to transfer with mechanical lift with large size sling with two person assist, assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed, set up assist with meal trays by offering to open packages and containers, cutting up meat/vegetables, use assuasive/adaptive equipment wheelchair and non-weight bearing to right lower extremity. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The resident required extensive assistance of two staff for bed mobility and transfers and was dependent on two staff for bathing. Review of the resident's activities daily preference revealed it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of the task bar revealed the resident's scheduled showers were Monday, Wednesday and Friday evenings. Review of the resident's shower documentation for September 2021 revealed no evidence the resident received a shower and/or bed bath on the scheduled days of 09/10/21, 09/13/21, 09/15/21, 09/17/21, 09/20/21, 09/22/21, 09/24/21, 09/27/21 and 09/29/21. Review of the resident's shower documentation for October 2021 revealed no evidence the resident received a shower and/or bed bath on the scheduled days of 10/04/21, 10/08/21, 10/11/21 and 10/18/21. On 10/18/21 at 3:39 P.M. interview with the resident revealed he had not received any showers since being admitted to the facility on [DATE]. On 10/19/21 at 8:45 A.M. observation of the resident revealed the resident's hair was greasy and unkempt. On 10/20/21 at 8:25 A.M. observation of the resident revealed the resident's hair was greasy and 365620 Page 11 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0677 unkempt. Level of Harm - Minimal harm or potential for actual harm On 10/20/21 at 11:25 A.M. interview with Registered Nurse (RN) #540 verified the resident had not had a shower since admission because the nursing assistant staff had reported the resident preferred a bed bath. The RN revealed she had not confirmed with the resident the preference for bathing. Residents Affected - Few 2. Review of the medical record for Resident #48 revealed an admission date of 05/17/17 with diagnoses including legal blindness, peripheral vascular disease, assistance with personal care and muscle wasting. Review of the activities of daily living plan of care, dated 05/24/17 revealed Resident #48 required assistance with bathing. Review of MDS 3.0 assessment, dated 09/01/21 indicated the resident required extensive physical assistance of two persons for transfers and personal hygiene. Resident #48 required extensive physical assistance from one person for bathing. Review of the progress notes, dated 08/01/21 through 10/18/21 revealed no documentation of Resident #48 refusing a shower or bath. Review of the State Tested Nursing Assistant (STNA) task documentation revealed Resident #48 was to receive a shower on Monday and Thursday and as needed on the day shift. Review of the documentation for 08/2021, 09/2021 and 10/2021 revealed Resident #48 received a shower/bath on the following dates: 08/12/21, 08/16/21, 09/06/21, 09/09/21, 09/13/21, 09/23/21, 09/27/21, 10/04/21 and 10/14/21. There was no documentation of a shower/bath or reason why a shower/bath was not provided as scheduled on 08/02/21, 08/05/21, 08/09/21, 08/23/21, 08/26/21, 08/30/21, 09/02/21, 09/30/21, 10/07/21 or 10/18/21. An interview on 10/18/21 at 10:14 A.M. with Resident #48 revealed she requested to be showered two times per week and had only received one or two showers here and there. An interview on 10/21/21 at 9:22 A.M. with Resident #48 revealed she was waiting on the STNA to take her to the shower room. An interview on 10/20/21 at 7:40 A.M. with STNA #420 revealed Resident #48 would often say she does not want a shower or bath. STNA #420 said a resident who refused shower or bath would be offered two times, and if the resident continued to refuse, she would notify the nurse. The STNA stated she would document the refusal in the task section of the care plan. An interview on 10/20/21 at 11:30 A.M. with Interim Director of Nursing (IDON) #325 revealed a resident who refused a bath or shower would be offered two times and the STNA would notify the nurse. The nurse would attempt and if the resident continued to refuse, the STNA would document in the task section the refusal. IDON DON #325 reviewed the task documentation and confirmed no refusals were documented for Resident #48. IDON #325 could not answer why Resident #48 did not receive showers as scheduled/requested. 365620 Page 12 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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 and interview the facility failed to ensure collaborative and coordinated care with Hospice to meet the total care needs of Resident #15. The facility failed to maintain any documentation from Hospice with regards to care or services provided in the resident's medical record. This affected one resident (#15) of one resident reviewed for Hospice services. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's physician's orders revealed an order, dated 04/21/21 to admit resident for Hospice services. Review of the plan of care, dated 04/23/21 revealed the resident had a terminal prognosis related to dementia with restlessness and increased agitation. Interventions included to encourage support system of family and friends. Allow compassionate immediate family visits per facility policy, Hospice and team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. Review of the plan of care, dated 05/04/21 revealed hospice/palliative care need due to terminal illness. Interventions included to administer medications per physician orders, allow patient/family to discuss feelings, assist to reposition, assist with activities of daily living (ADL) care and pain management as needed, collaborate care with hospice, dietary to evaluate and modify meal and snack plan as needed, encourage to participate in activities as able, honor advanced directives, Hospice services with with Hospice staff to visit to provide care, assistance and/or evaluation due to terminal illness; will collaborate all care/plan of care with Hospice. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The MDS indicated the resident had less than six months life expectancy and received Hospice services. Review of the resident's medical record failed to provide any documentation or evidence of coordination of care from Hospice for Resident #15. On 10/19/21 at 2:23 P.M. interview with Licensed Practical Nurse (LPN) #900 revealed Resident #15 had been admitted to Hospice on 04/22/21. However, Hospice staff had their own charting system and doesn't leave any documentation with the facility. On 10/20/21 at 2:49 P.M. interview with Medical Records #215 verified the facility had no documentation from the resident's Hospice company. Review of the facility Hospice contract, dated 11/30/17 revealed the facility and hospice would prepare and maintain a complete medical record for Hospice residents receiving facility services in 365620 Page 13 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0684 Level of Harm - Minimal harm or potential for actual harm accordance with the agreement and would include all treatments, progress notes, authorizations, physician's orders and other pertinent information. Documentation of care and services provided by Hospice would be filed and maintained in the facility chart. Residents Affected - Few 365620 Page 14 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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 observation, record review and interview the facility failed to ensure Resident #54's left hip was comprehensively assessed prior to implementing a skin treatment and failed to ensure a physician order was in place for the treatment. This affected one resident (#54) of three sampled residents reviewed for skin/wound care. Residents Affected - Few Findings include: Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the care plan, revised 08/12/21 revealed Resident #54 was at risk for alteration in skin integrity and had a history of scratching arms and legs. Interventions included a low air loss (Hospice) mattress. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting and dressing and required supervision with two person physical assist for eating and drinking. On 10/19/21 at 2:20 P.M. Resident #54 was observed with a foam border dressing located on her left hip which was dated 10/13/21. At the time of the observation, interview with State Tested Nursing Assistant (STNA) #150 and STNA #335 verified Resident #54 had a foam border dressing on her left hip which contained the date 10/13/21. No additional information was provided related to why the dressing was in place at that time. On 10/20/21 at 4:15 P.M. Resident #54 was observed to continue to have a foam border dressing on her left hip which contained the date 10/13/21. At the time of the observation, interview with Registered Nurse (RN) #120 and Licensed Practical Nurse (LPN) #160 verified Resident #54 had a foam border dressing to her left hip which contained the date 10/13/21. No additional information was provided by the RN or LPN related to why the dressing was in place. Review of the active physician's orders for October 2021 revealed no current order for a treatment to the resident's left upper hip. In addition, review of the resident's assessments and progress notes from 10/13/21 through 10/20/21 revealed no assessment of the resident's left hip or information related to why the foam border dressing was applied on 10/13/21. 365620 Page 15 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0688 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. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the facility policy titled Restorative Nursing Guidelines the facility failed to ensure Resident #17 received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Actual Harm occurred when Resident #17, who was cognitively impaired and required extensive assistance/dependence on staff for activities of daily living was identified to have a decline in range of motion of her neck and left wrist with new onset contractures resulting in the resident's neck being bent to the left side with her head touching her shoulder and her left hand being in a bent downward position from her wrist. There was no evidence of a comprehensive and individualized range of motion program being implemented following therapy recommendations in June 2021 to prevent the declines and new onset contractures from occurring. This affected one resident (#17) of one resident reviewed for range of motion. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/15/21. The resident was admitted from the hospital after treatment for a cerebral vascular accident. Review of an admission Minimum Data Set (MDS) 3.0 assessment, dated 04/22/21 revealed the resident had short and long term memory impairment, required extensive assistance from two staff with transfers, locomotion, dressing and hygiene. The resident required extensive assistance from one staff for eating. The MDS assessment revealed Resident #17 had impairment in range of motion of the upper and lower extremities on one side. Record review revealed the resident was provided physical therapy from 04/16/21 until 06/24/21. The physical therapy evaluation revealed the resident was exhibiting a new onset of decrease in functional mobility. Notes indicated the resident previously lived in an apartment independently. The notes indicated the resident's left lower extremity range of motion was impaired but without contractures. The physical therapy discharge summary on 06/24/21 revealed the resident required substantial/maximal assistance with transfers from chair to bed, was dependent for toilet transfer and no longer allowed attempts at walking. The discharge summary indicated follow up care was to include a restorative range of motion program. However, there was no evidence a restorative range of motion program was implemented. Record review revealed the resident was provided with occupational therapy from 04/16/21 until 06/24/21. The goal was for the resident to increase ability to engage in self care. The notes indicated the resident's right upper extremity range of motion was within normal limits. The left upper extremity range of motion was impaired but no muscle contraction was detected. Review of the occupational therapy Discharge summary, dated [DATE] revealed Resident #17 was demonstrating left neck flexion and at time of discharge had increased tightness of left upper extremity noted but the resident was unwilling to let the therapist position left upper extremity in any way. Recommendations included 24 hour care and assistance with all activities of daily living including self feeding. Chair with head/neck support recommended when out of bed to facilitate most appropriate positioning. There was no evidence any other treatment was recommended for the neck flexion or tightness in left upper extremity 365620 Page 16 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0688 at the time of therapy discharge. Level of Harm - Actual harm Review of Resident #17's plan of care revealed the resident had an activity of daily living deficit as evidenced by muscle atrophy and weakness multiple sites related to recent cerebral vascular accident. The care plan was initiated 04/16/21. The goal was to improve activity of daily living self performance. The only intervention included was physical therapy (which was discontinued 06/24/21). There was no evidence of any interventions in place after therapy was discontinued to improve or maintain the resident's range of motion. Residents Affected - Few Review of the quarterly MDS 3.0 assessment, dated 07/23/21 revealed the resident was totally dependent upon two staff for transfers, required extensive assistance from staff with dressing, eating, and hygiene, and now had impairments in range of motion on both sides including the upper and lower extremities. Record review revealed no evidence any treatment related to range of motion was provided between 06/24/21 and 10/05/21 for the resident. On 10/05/21 an occupational therapy evaluation was completed. The evaluation revealed the reason for the referral was due to worsening of range of motion. The resident's left wrist was noted to be at a 100 degree position relative to left radius and ulna, with increased tightness so much so that changes in range of motion during flexion/extension were not measurable. The evaluation indicated the resident had functional limitations due to contractures. The evaluation also revealed decreased range of motion of the left upper extremity and neck limited participation in self care without pain as well as increased risk for skin breakdown. Occupational therapy was initiated to address contracture impairment. The notes indicated Resident #17 demonstrated poor supine positioning with her head laterally flexed and rotated to left. Left upper extremity at risk for worsening contracture. Therapy to trial orthotic devices to manage decreased range of motion and increased tightness. Resident to participate in manual therapy to manage decreased range of motion. On 10/18/21 at 12:06 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder). The resident's left hand was contracted downward at the wrist. Staff were observed feeding the resident her lunch with her head bent completely to the left side. On 10/18/21 at 2:41 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. On 10/19/21 at 7:48 A.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. Staff were observed feeding the resident her breakfast with her head bent completely to the left side. On 10/19/21 at 9:50 A.M. interview with Resident #17's brother revealed when the resident was in the hospital her head was not leaning to the left and now it was. The brother indicated he felt this had been a decline for the resident since her admission to the facility. The resident's brother revealed about a week ago staff had talked to him about the resident wearing a collar on her neck but he was not aware if this had been implemented. On 10/19/21 at 1:34 P.M. and 4:41 P.M. Resident #17 was observed in bed with her head bent to the left (touching her shoulder) and her left hand contracted downward at the wrist. 365620 Page 17 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0688 Resident #17 was not observed to be out of bed on 10/18/21 or 10/19/21. Level of Harm - Actual harm On 10/20/21 at 7:15 A.M. interview with Occupational Therapist (OT) #415 revealed he had provided occupational therapy for Resident #17 during the period of 04/16/21 to 06/24/21. OT #415 revealed the resident's left wrist was starting to contract during that time but that the resident would not allow him to work with her left arm. OT #415 also indicated the resident had some neck flexion starting at that time and she would allow him to provide range of motion for her neck but the neck had since worsened. OT #415 revealed he was not sure what had been done to prevent the resident's neck from further contracting after she was discontinued from therapy services on 06/24/21. OT #415 verified his discharge recommendations on 06/24/21 did not include any type of passive range of motion for her neck or left upper extremity. OT #415 verified both the resident's left wrist and neck had declined in range of motion. He stated since therapy restarted 10/05/21, she sometimes allowed him to provide range of motion and sometimes not. On 10/11/21 the resident allowed nine minutes of stretching of her neck. He stated her neck was at approximately 60 degrees laterally flexed and with range of motion he could get it to midline. The resident's left wrist was at approximately 90 degrees flexion and he could get it to about 30 degrees with range of motion now. OT #415 revealed he planned to attempt splinting for the resident's neck and wrist. Residents Affected - Few On 10/20/21 at 8:40 A.M. observations of an occupational therapy session revealed Resident #17 was up in a chair with lateral neck support. The resident did allow intermittent stretching of her neck to almost midline. On 10/20/21 at 11:08 A.M. interview with MDS Coordinator #145 revealed when Resident #17 was first admitted she had limitations described as left sided weakness on one side. Then when she completed the quarterly MDS in July 2021, she noticed issues on the right side. MDS Coordinator #145 revealed she did not know what the issue was that prompted her to mark both sides as having limitations in range of motion as she made no notes. During the interview, MDS Coordinator #145 also confirmed there was no plan of care in place related to range of motion. She stated when range of motion was recommended by therapy, if it was done, it was documented by nursing assistant staff. MDS Coordinator #145 confirmed there was no evidence of any range of motion program being in place or provided for Resident #17 between 06/24/21 and 10/05/21. On 10/20/21 at 2:00 P.M. interview with Interim Director of Nursing #325 and Director of Rehab #125 confirmed there was no treatment provided for Resident #17 after her therapy was discontinued on 06/24/21. Review of the facility policy titled Restorative Nursing Guideline, dated 08/2019 revealed restorative nursing care included nursing interventions that help to maintain the patient's highest level of function and prevent unnecessary decline in function. Restorative nursing programs were individualized to specific patient needs and have many tangible positive effects including preventing further decline and reducing risk of complications related to immobility. Restorative nursing does not require a physician's order. Patients may enter a restorative nursing program in several ways including after discharge from a skilled physical, occupational, or speech rehabilitation program. Techniques include passive range of motion and active range of motion. Interventions were provided by nursing staff who have completed the appropriate competency evaluation. 365620 Page 18 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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 observation, record review and interview the facility failed to ensure fall risk interventions were in place as care planned to prevent falls for residents. This affected three residents (#24, #44 and #54) of three residents reviewed for falls. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, history of falls, anxiety, depression, and cognitive communication deficit. Review of the care plan, revised 11/11/20 revealed Resident #44 was at risk for falls. Interventions included to have bed in lowest position, non-skid socks or shoes on, leave bathroom light on, and leave bathroom door ajar. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed Resident #44 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and limited assistance from one staff member for transfers. The resident was assessed to have suffered one fall without major injury since the prior assessment. On 10/20/21 at 9:40 A.M. Resident #44 was observed in bed. The resident's bed was not in the lowest position at the time of the observation as care planned. Interview with State Tested Nursing Assistant (STNA) #212 at the time of the observation, verified Resident #44's bed was not in the lowest position. 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparalysis following cerebral infarction affecting the right dominant side, muscle wasting and atrophy and need for assistance with personal care. Review of the care plan, revised 08/12/20 revealed Resident #24 was at risk for falls. Interventions included bed in low position, low bed, air mattress with bolsters to bed and implement use of grabbing assist tool. Review of the annual MDS 3.0 assessment, dated 08/03/21 revealed Resident #24 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, toileting, dressing and personal hygiene. On 10/18/21 at 2:41 P.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the room. On 10/19/21 at 8:57 A.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the room. On 10/19/21 at 2:05 P.M. Resident #24 was observed in bed with the bed 365620 Page 19 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the room. On 10/19/21 at 2:05 P.M. interview with STNA #360 verified Resident #24 was in bed and the bed was in a high position, there were no bolsters located on the side of the resident's mattress and no grabbing assist tool was observed in the resident's reach or in the resident's room. On 10/20/21 at 8:50 A.M. Resident #24 was observed in bed with the bed in a high position. No bolsters were observed to the resident's mattress and no grabbing assist tool was observed within the resident's reach or in the resident's room On 10/20/21 at 8:50 A.M. interview with Registered Nurse (RN) #975 verified Resident #24 was in bed with the bed in a high position, there were no bolsters located on the side of the resident's mattress, and no grabbing assist tool in the resident's reach or in the resident's room as per the resident's fall risk plan of care. 3. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including anemia, depression, hyperlipidemia, diabetes mellitus, muscle weakness and need for assistance with personal care. Review of the care plan, revised 04/27/21 revealed Resident #54 was at risk for falls. Interventions included non-skid socks on when in bed, scoop/perimeter mattress, staff education on low bed, implement use of hipsters and mattress on floor at bedside. Review of the quarterly MDS 3.0 assessment, dated 09/04/21 revealed Resident #54 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 00. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting and dressing and to require supervision with two person physical assist for eating and drinking. This resident was not assessed to have had any falls since the prior assessment. Review of the nursing progress note, dated 09/29/21 at 9:15 A.M. revealed Resident #54 was found lying on the floor next to her bed which had been elevated for the breakfast meal and not been placed back down in low position afterward. On 10/18/21 at 10:10 A.M. Resident #54 was observed lying on a mattress on the floor beside her bed and was not wearing hipsters. On 10/18/21 at 2:33 P.M. Resident #54 was observed lying on a mattress on the floor beside her bed and was not wearing hipsters. On 10/19/21 at 8:53 A.M. Resident #54 was observed in bed. The resident's bed was in a high position and the resident was not observed to be wearing hipsters. On 10/19/21 at 2:20 P.M. Resident #54 was observed in bed and not observed to have hipsters on. On 10/19/21 at 2:20 P.M. interview with STNA #335 verified Resident #54 did not have hipsters on but was supposed to according to the [NAME] and care plan for the resident. 365620 Page 20 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and facility policy and procedure review the facility failed to ensure residents were assessed for oxygen use, had physician's orders in place for oxygen and/or failed to ensure oxygen tubing was dated and stored in a sanitary manner. This affected five residents (#15, #61, #226, #228 and #328) of six residents reviewed for oxygen therapy. Residents Affected - Some Findings include: 1. Review of Resident #15's medical record revealed an admission date of 09/19/17 with the admitting diagnoses of dementia, adult failure to thrive, anorexia, abnormal weight loss, personal history of COVID-19, seasonal allergic rhinitis, rosacea, major depressive disorder, glaucoma, peripheral vascular disease, dysphagia and age related debility. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/21 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of one. The assessment indicated the resident had not used oxygen. Review of the resident's monthly physician's orders for October 2021 revealed an order, dated 10/18/21 for oxygen at two liters per minute (LPM) as needed for shortness of breath. Review of the resident's plan of care revealed no care plan addressing the resident's respiratory status and oxygen use. On 10/19/21 at 2:20 P.M. observation of the resident's oxygen concentrator revealed it was powered on and set at two LPM. The resident's oxygen tubing was laying on the floor and had no date identifying the date the tubing was opened for use. On 10/18/21 at 11:21 A.M. interview with Licensed Practical Nurse (LPN) #900 verified the resident's oxygen tubing had no date identifying when it had been opened and was not being stored in a sanitary manner. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 2. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's admission Evaluation, dated 09/10/21 revealed the resident was admitted with no special treatment and/or procedure. The resident had no baseline plan of care related to oxygen use. Review of the resident's comprehensive MDS 3.0 assessment, dated 09/17/21 revealed the resident had 365620 Page 21 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0695 Level of Harm - Minimal harm or potential for actual harm clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The assessment indicated the resident received oxygen therapy. Review of the resident's monthly physician's orders for October 2021 identified no orders for oxygen. Residents Affected - Some Review of the resident's plan of care failed to identify a care plan related to oxygen use. On 10/18/21 at 3:46 P.M. observation of the resident's oxygen tubing revealed the tubing had no date identifying when the tubing was opened. The tubing was wrapped around the handle on the resident's night stand. On 10/18/21 at 3:50 P.M. interview with LPN #900 verified the resident's oxygen tubing was not dated identifying when it was opened and was not stored in a sanitary manner. On 10/20/21 at 10:45 A.M. interview with Interim Director of Nursing (IDON) #325 verified the resident had no physician order for oxygen. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 3. Review of Resident #226's medical record revealed an admission dated of 10/13/21 with the admitting diagnoses of pneumonia due to COVID-19, symbolic dysfunction, hypertension, gastro-esophageal reflux disease, hypothyroidism, anxiety disorder and major depressive disorder. Review of the resident's discharged instructions from acute care hospital stay revealed the resident's oxygen use had peaked at 11 liters but the resident now required oxygen at 3 to 5 liters per minute via nasal cannula to maintain oxygen saturations. Review of the resident's admission evaluation, dated 10/13/21 identified the resident as having no special treatments and/or procedures for respiratory status. Review of the plan of care, dated 10/15/21 revealed the resident was at risk and/or has a respiratory impairment. Interventions included obtain pulse oximetry and report abnormal findings, administer medications/treatments as ordered per physician, elevate the head of the bed and evaluate lung sound and vital signs as needed. Review of the resident's monthly physician's orders for October 2021 identified no orders for oxygen or pulse oximetry. Review of the resident's comprehensive MDS 3.0 assessment with assessment reference date (ARD) of 10/20/21 was still in progress. Review of the resident's respiratory surveillance assessments from 10/14/21 to 10/19/21 revealed the resident's oxygen saturation rate was 100% on room air. The assessment failed to identify the 365620 Page 22 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0695 resident's oxygen use. Level of Harm - Minimal harm or potential for actual harm Review of the resident's progress notes from 10/13/21 through 10/19/21 revealed no documentation regarding the resident's use of oxygen. Residents Affected - Some On 10/18/21 at 11:15 A.M. observation of the resident revealed she had oxygen at two LPM via nasal cannula. Further observation revealed the resident's oxygen tubing had no date identifying when it had been opened. On 10/18/21 at 11:20 A.M. interview with the LPN assigned to care for Resident #226 verified the oxygen tubing had not been dated to indicate when it had been opened. On 10/19/21 at 1:57 P.M. interview with IDON #325 verified the resident had no order for oxygen use and had not been assessed for oxygen use. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 4. Review of Resident #228's medical record revealed an admission date of 10/12/21 with the admitting diagnoses of atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, severe morbid obesity, hypertension, anxiety disorder, asthma and major depressive disorder. Review of the resident's admission Evaluation dated 10/12/21 revealed the resident required oxygen therapy. Review of the resident's plan of care, dated 10/14/21 revealed the resident had a respiratory impairment related to asthma and congestive heart failure. Interventions included evaluate lung sounds, vital signs as needed, obtain labs as ordered and notify physician of results, provide assistance with activities of daily living to conserve energy, obtain pulse oximetry and report abnormal findings, administer medications/treatments per physician orders, elevate the head of bed, administer oxygen as per physician's orders at 2 liters per minute via nasal cannula and reports signs of infection or edema. Review of the resident's monthly physician's orders for October 2021 identified orders dated 10/12/21 for oxygen at two LPM via nasal cannula continuously. Review of the resident's Treatment Administration Record (TAR) revealed the resident received oxygen at two LPM via nasal cannula. Review of the resident's comprehensive MDS 3.0 assessment with assessment reference date (ARD) of 10/19/21 revealed it was still in progress. On 10/18/20 at 11:09 A.M. observation of the resident's oxygen tubing revealed no date identifying when the tubing had been opened. On 10/18/21 at 11:20 A.M. interview with LPN #900 verified the resident's oxygen tubing was not 365620 Page 23 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0695 dated identifying when it had been opened. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). Residents Affected - Some 5. Review of the medical record for Resident #328 revealed an admission date of 10/15/21 with diagnosis including pneumonia unspecified organism, anxiety and chronic obstructive pulmonary disorder. Review of the physician's orders for 10/2021 revealed the resident had an order for oxygen at two liters per minute via nasal cannula. Review of the progress notes from 10/15/21 through 10/20/21 revealed Resident #328 received a respiratory assessment three times daily. The assessment revealed the resident was on oxygen at two liters per minute via nasal cannula and oxygen saturations were in the mid 90's. Review of the respiratory care plan dated 10/16/21 revealed Resident #328 was to receive oxygen as ordered. An interview on 10/19/21 at 3:40 P.M. with Resident #328 revealed he was on three liters of oxygen at home prior to admission to hospital. An observation on 10/18/21 at 11:25 A.M. of Resident #328 revealed the oxygen tubing was not dated, the oxygen was set at three liters per minute via nasal cannula but was not hooked up to the humidification bottle on the concentrator. An interview on 10/18/21 at 11:25 A.M. with Licensed Practical Nurse (LPN) #900 confirmed the oxygen tubing was not dated or hooked up to the humidification bottle on the concentrator. An interview on 10/19/21 at 8:25 A.M. with LPN #420 confirmed the physician's order for Resident #328 was for oxygen at two liters per minute via nasal cannula. LPN #420 confirmed Resident #328 was receiving oxygen at three liters per minute via nasal cannula. Review of the facility policy titled Oxygen Administration, dated 07/2017 revealed the purpose of the policy was to describe the method of delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included to verify the physician's order. The application of a nasal cannula included to ensure that tubing and cannula or mask was labeled with date and time (it was first opened/used). 365620 Page 24 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, record review and interview the facility failed to ensure pharmacy services met the needs of Resident #4 when insulin was not available in the emergency supply stock. This affected one resident (#4) of seven residents observed for medication administration. Findings include: Record review revealed Resident #4 had a physician's order for Novolin N insulin 16 units daily (scheduled at 8:00 A.M.) for a diagnosis of diabetes mellitus. On 10/20/21 at 8:30 A.M. Registered Nurse (RN) #510 was observed administering medications for Resident #4. During the observation, RN #510 revealed the Novolin N insulin was not available for Resident #4. Staff then called the physician and got a physician's order to substitute Humulin N insulin, as the Novolin N insulin was not available in the facility stock medications. However, when RN #510 went to the stock medication, Humulin N insulin was not available either. Therefore, Resident #4 was unable to receive her scheduled insulin at that time. RN #510 indicated the pharmacy was notified and the insulin would be sent at a later time. Review of the facility list of emergency stock medications to be available revealed it included Novolin N and Humulin N insulin. Interview with Interim Director of Nursing #325 on 10/21/21 at 11:01 A.M. revealed she did not know why the insulin was not available in the emergency stock as it should have been. At 11:45 A.M. she revealed the facility did not have a policy on emergency stock medications, just a list of medications to be available. 365620 Page 25 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0758 Level of Harm - Actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #46's medical record revealed an original admission date of 09/25/15 with diagnoses including Alzheimer's disease, chronic pain, nonthrombocytopenia purpura, anxiety, atherosclerotic heart disease, cardiac pacemaker, bradycardia, diabetes mellitus type II, anorexia, dementia with behavioral disturbance, debility, dysphagia, cognitive communication deficit, depression, peripheral vascular disease, hyperlipidemia, COVID-19, muscle wasting and atrophy, hypertension and atrial flutter. Review of the resident's quarterly MDS 3.0 assessment, dated 08/31/21 revealed the resident had a BIMS score of 3, indicating severe cognitive impairments. Review of physician's orders revealed an order (dated 09/01/21) for Risperidone 1 mg by mouth daily at bedtime for dementia related to agitation/irritability. The resident also had an order (dated 09/02/21) for Risperidone 0.75 mg by mouth daily in the morning On 10/20/21 at 11:02 A.M. interview with the Director of Nursing verified the resident was currently receiving two doses of an antipsychotic medication, Risperidone for a diagnosis of dementia with behavioral disturbance. The Director of Nursing verified these were not appropriate medications for the resident's diagnoses. No additional information was provided during the survey to justify the use of the medication for Resident #46. Based on record review and interview the facility failed to adequately monitor and assess Resident #44 for adverse consequences following the initiation of the psychoactive medication, Ambien. The facility also failed to provide an appropriate diagnosis for the use of the antipsychotic medication, Risperidone for Resident #46. Actual harm occurred on 07/23/21 when Resident #44 sustained a fall resulting in a fractured arm (humerus) related to possible side effects of the new Ambien medication being prescribed for the resident without proper monitoring and notification of the physician of the presence of adverse side effects prior to the resident's fall/fracture. This affected one resident (#44) of three residents reviewed for falls and one resident (#46) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, history of falls, anxiety, depression and cognitive communication deficit. Review of the care plan, revised 11/11/20 revealed the resident was at risk for falls. Interventions included to have bed in lowest position, non-skid socks or shoes on, leave bathroom light on and leave bathroom door ajar. Review of the physicians' orders for July 2021 revealed on 07/01/21 a new order was obtained for Ambien 10 milligrams (mg), one tablet every night for insomnia. 365620 Page 26 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0758 Level of Harm - Actual harm Review of the nursing progress note, dated 07/02/21 at 3:41 A.M. revealed the resident was documented to have had an adverse reaction to Ambien as she had been excitable and yelling all night and had been attempting to wander into other resident's rooms. There was no evidence the physician was notified of the adverse reaction at that time. Residents Affected - Few Review of the Treatment Administration Record (TAR) for 07/2021 revealed Resident #44 was documented to have received one Ambien 10 mg tablet every night from 07/02/21 through 07/23/21. There was no evidence the resident was assessed/monitored for side effects/additional adverse consequences of the medication during this time period. Review of a nursing progress note, dated 07/23/21 at 2:30 A.M. revealed Resident #44 was heard yelling out and was found lying on the floor of her room complaining of pain to her left arm. The Nurse Practitioner (NP) was notified of the fall and gave orders for the resident to be sent to the hospital where she was diagnosed with a fractured humerus. The resident was re-admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/27/21 revealed Resident #44 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and limited assistance from one staff member for transfers. This resident was assessed to have suffered one fall without major injury since the prior assessment. Review of the facility list of resident falls from 10/01/20 through 10/18/21, provided by Registered Nurse (RN) #325, revealed Resident #44 was identified to have one fall during this time period, the fall on 07/23/21. On 10/20/21 at 10:30 A.M. interview with Interim Director of Nursing (IDON) #325 revealed she was not aware of any adverse side effects of the medication prior to the resident's fall/fracture on 07/23/21. IDON #325 verified the lack of evidence of monitoring of the medication between 07/02/21 and 07/23/21. IDON #325 started at the facility the beginning of July 2021. On 10/20/21 at 1:20 P.M. interview with Medical Director (MD) #675 verified he had ordered Ambien for Resident #44 but could not recall being notified of any adverse side effects of the medication by facility staff. MD #675 revealed if he had been notified of adverse side effects of the Ambien therapy, he would have placed the medication on hold until he could have reassessed Resident #44. Medication guidelines reveal Ambien is designed for short term use only and commonly prescribed for anxiety related insomnia and other sleeping difficulties. The medication may cause some people, especially older persons, to become drowsy, lightheaded, dizzy, unsteady, or less alert than they are normally, which may lead to falls as seniors are more likely to be more sensitive to the drugs' effects than younger adults. The medication can cause confusion and memory problems that more than double the risk for falls and fractures in the elderly. The recommended dose of Ambien in these patients is 5 milligrams once daily before bedtime. 365620 Page 27 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview, and review of the facility policy and procedure for medication administration the facility failed to maintain a medication error rate less than five (5) percent (%). The medication error rate was calculated to be 8.33% and included three medication errors of 36 medication administration opportunities. This affected two residents (#4 and #70) of seven residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #70 revealed a physician's order dated 12/28/20 for Miralax 17 grams one time a day (scheduled for 8:00 A.M.) for constipation. On 10/19/21 at 8:05 A.M. Licensed Practical Nurse (LPN) #160 was observed to administer medications to Resident #70. During the administration, the LPN was not observed to administer Miralax (a laxative medication). However, the LPN signed off she administered the medication on 10/19/21 at 8:00 A.M. On 10/19/21 at 10:00 A.M. interview with LPN #160 verified she had forgotten to administer the Miralax medication to the resident but had documented it had been administered. 2. Review of the medical record for Resident #4 revealed a physician's order for Eliquis 5 mg two times daily (scheduled for 8:00 A.M. and 8:00 P.M.) for atrial fibrillation. On 10/20/21 at 8:30 A.M. Registered Nurse (RN) #510 was observed to administer medications to Resident #4. RN #510 revealed he was administering nine pills. The pills observed included Mucus Relief 400 milligrams (mg), Ferrous Sulfate 325 mg, Omeprazole 20 mg, Senna S 8.6 mg, Allopurinol 100 mg, Atorvastatin 20 mg, Benztropine 0.5 mg, Buspirone 5 mg and Lasix 40 mg. The RN verified these medications and was observed to administer them to the resident. At the time of the observation, Resident #4 was not observed to receive Eliquis 5 mg. However, review of the medication administration record revealed the Eliquis was documented as being given on 10/20/21 at 8:29 A.M., the same time the nine observed medications were signed off as given. On 10/20/21 at 10:05 A.M. interview with RN #510 revealed he administered the Eliquis medication to the resident at a later time after the surveyor was no longer watching. Review of the facility policy on Medication Administration, dated 3/2010 revealed the nurse was to remain with the resident until administration of medication was complete, then document their initials on the medication administration record for each medication administered. Interview with Interim Director of Nursing #325 on 10/20/21 at 10:40 A.M. confirmed the Eliquis was documented as given at 8:29 A.M. She confirmed RN #510 stated he gave the medication after it was documented as given. In addition, Resident #4 had a physician's order for Novolin N insulin 16 units daily (scheduled at 8:00 A.M.) for diabetes mellitus During the observation of the medication administration on 10/20/21 at 8:30 A.M. RN #510 revealed the Novolin N insulin was not available for Resident #4. Staff then called the physician and got a 365620 Page 28 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0759 Level of Harm - Minimal harm or potential for actual harm physician's order to substitute Humulin N insulin, as the Novolin N insulin was not available in the facility stock medications. However, when RN #510 went to the stock medication, Humulin N insulin was not available either. Therefore, Resident #4 was unable to receive her scheduled insulin at that time. RN #510 revealed the pharmacy was notified and the insulin would be sent at a later time. Residents Affected - Few 365620 Page 29 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the facility policy and procedure the facility failed to ensure each resident received food that was palatable and failed to ensure meals were served at appetizing temperatures. This affected seven residents (#12, #28, #47, #48, #67, #70, and #75) of 27 sampled residents. The facility census was 87. Residents Affected - Some Findings include: The following food/meal concerns were identified during the annual survey: a. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including repeated falls, anxiety disorder, and rheumatoid arthritis. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #12 had slightly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. The resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting. Interview with Resident #12 on 10/18/21 at 10:44 A.M. revealed the resident voiced concerns the food/meals served was often cold and tasted badly. b. Review of a MDS 3.0 assessment, dated 09/03/21 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Interview with Resident #47 on 10/18/21 at 10:51 A.M. revealed concerns the food in general was not good and was not hot enough when served. c. On 10/18/21 at 11:21 A.M. interview with a resident who wished to remain anonymous revealed concerns the food was not good and was sometimes cold when served. d. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including hypertension, obstructive and reflux uropathy and chronic obstructive pulmonary disease. Review of the admission MDS 3.0 assessment, dated 09/14/21 revealed Resident #75 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14. The resident was assessed to require extensive assistance from two staff members with bed mobility, transfers, and toileting and was independent for eating with setup help only. Interview with Resident #75 on 10/18/21 at 11:49 A.M. revealed the resident voiced concerns the food was often cold. e. Review of a MDS 3.0 assessment, dated 08/07/21 revealed Resident #28 had a BIMS score of 15, indicating intact cognition. Interview with Resident #28 on 10/18/21 at 12:08 P.M. revealed the food was awful and had no taste. 365620 Page 30 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some f. Observations of the lunch meal on the 200 hall on 10/18/21 revealed the unheated cart containing the resident lunch trays arrived on the hall at 11:43 A.M. The lunch meal consisted of fish, noodles, spinach, bread, and a lemon bar. On 10/18/21 at 12:14 P.M. Resident #48, who had not received her tray yet, was asking if lunch had been served. Her lunch tray remained on the cart in the hall. On 10/18/21 at 12:15 P.M. (32 minutes after they were delivered) there were still three trays remaining on the lunch cart in the hall (Resident #32, #48, and #67). State Tested Nursing Assistant #555 revealed at that time, that those three residents needed assistance with eating and there were only two nursing assistants on the hall at that time and they were both assisting other residents to eat. Resident #48 was served her lunch at 12:23 P.M. (40 minutes after the trays were delivered to the hall). The surveyor was unable to ask Resident #48 about the temperature of the food when it was served as Resident #48 refused to even taste the food and requested a sandwich instead. Resident #67 was served her lunch at 12:30 P.M. (47 minutes after the trays were delivered to the hall). On 10/18/21 at 12:30 P.M. temperatures were taken of the tray remaining on the cart belonging to Resident #32. (It was determined at that time that Resident #32 was out for an appointment). The food temperatures were taken by Registered Dietician (RD) #565 at 12:30 P.M. on 10/18/21. The fish was 110 degrees, the noodles were 103 degrees, and the spinach was 114 degrees. The fish, noodles, and spinach were tasted by RD #565, who stated the food was not hot enough and should be at least 120 degrees when served. She stated the food should be served within 20-30 minutes of arriving on the hall. The surveyor also tasted the fish, noodles, and spinach. The food was cool to taste. Review of the facility policy titled Food Temperatures at Point of Service, dated 11/2020 revealed trays were to be delivered promptly after arriving in patient care areas. The policy further revealed the regulation that addressed food temperatures at point of service to the patient was Ftag 804. Proper temperature means both appetizing to the resident and minimizing the risk for scalding and burns. 365620 Page 31 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

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 observation, record review, review of the Centers for Disease Control (CDC) guidelines, interview and facility policy and procedure review the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE), proper isolation procedures and during blood glucose monitoring to prevent the spread of infection inlcuding COVID 19. This affected eight residents (#62, #25, #329, #70, #61, #14, #28 and #75) and had the potential to affect all 87 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #14 revealed a physician's order on 08/16/21 to perform a finger stick blood sugar test before meals and at bedtime. On 10/19/21 at 11:00 A.M. Registered Nurse (RN) #975 was observed to perform a finger stick blood sugar test for Resident #14. RN #975 used a lancet to obtain a drop of blood from the resident's finger. The drop of blood was applied to a test strip which had been inserted into the blood glucose meter to measure the resident's blood glucose. The resident's blood sugar was 351. RN #975 was not observed to sanitize the blood glucose meter prior to using it on Resident #14. RN #975 was not observed to sanitize the blood glucose meter after using it on Resident #14. She then took the same blood glucose meter and performed a finger stick blood sugar test for Resident #28 on 10/19/21 at approximately 11:10 A.M. Resident #14's blood sugar was 198. Medical record review revealed Resident #14 had a physician's order on 09/22/21 to have a finger stick blood sugar test before meals. Interview with RN #975 on 10/19/21 at approximately 11:15 A.M. confirmed she did not sanitize the blood glucose meter after using it on Resident #14 or prior to using it on Resident #28. She confirmed she was supposed to clean the blood glucose meter between residents using a germicidal wipe. The facility identified nine residents, Resident #14, #24, #28, #44, #45, #57, #68, #72, and #75 who received blood sugar monitoring using this blood glucose meter. None of those residents were noted to have any blood bourne diseases such as HIV/Aids, Hepatitis B or C. Review of the facility policy on Glucose Blood Monitoring dated 03/2001 and updated 1/2010, 7/2010, 2/2011 and 8/2014 revealed after performing a blood glucose test, the blood glucose meter was to be cleaned with an EPA approved bleach wipe or approved germicidal disinfectant per manufacturer instructions. 2. Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. 365620 Page 32 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the resident's monthly physician's orders for October 2021 identified an order dated 10/15/21 for contact isolation related to shingles and Acyclovir 800 milligrams (mg) by mouth four times a day for shingles for seven days. Review of the progress note, dated 10/15/21 revealed staff observed a small fluid filled pustules with a small reddened area around the pustules. The physician was notified and ordered Acyclovir 800 milligrams by mouth four times a day for seven days for shingles. Review of the resident's plan of care dated 10/15/21 revealed the resident had infection of the skin related to shingles to left side of coccyx. Interventions included to administer medications per physician's orders, contact isolation related to shingles, maintain precautions as indicated, obtain labs as ordered and notify physician of results and record temperature as clinically indicated. On 10/18/21 at 3:39 P.M. observation of the resident revealed she was sitting in her room watching television. There was no evidence the resident was in isolation at that time. On 10/19/21 at 8:45 A.M. observation of the resident revealed she had been placed in contact isolation. On 10/19/21 at 8:45 A.M. interview with State Tested Nursing Assistant (STNA) #245 revealed the resident was on contact isolation for shingles and confirmed the resident had not been in contact isolation prior to 10/19/21. On 10/20/21 10:06 AM interview with Registered Nurse (RN) #540 verified the resident was to be placed on contact isolation on 10/15/21. Review of the facility policy titled, Contact Precautions, dated 07/2021 revealed in addition to standard precautions, the following measures were necessary for contact precautions: wear gloves for any interactions with patient or the environment, wear gloves when in direct contact with a resident who was infected or colonized with organisms that were transmitted by direct contact, change gloves after contact with infective material, avoid contaminating other surfaces with gloved hands, apply gloves before entering and remove gloves before leaving the resident's room and immediately wash hands with an antimicrobial agent or use alcohol-based hand sanitizer, wear gown when clothing anticipated to come in contact with the resident, environmental surfaces or items in room contaminated and apply gown upon entry and remove gown before leaving room and immediately wash hands with an antimicrobial agent or use alcohol-based sanitizer. 4. On 10/18/21 at 11:30 A.M. State Tested Nursing Assistant (STNA) #655 was observed to exiting Resident #62's room wearing an N95 face mask and a face shield. Resident #62 was observed to be on transmission based droplet precautions due to displaying respiratory symptoms. Upon exiting the resident's room, STNA #655 did not remove her face shield and was not observed to clean the face shield with a recommended disinfectant. The STNA was then observed to walk down the hallway and outside the double closed doors to obtain a clean sheet from the linen cart located just outside the doors. An interview on 10/18/21 at 11:33 A.M. with STNA #655 confirmed she did not properly clean her face shield upon exiting Resident #62's room. The STNA verified the resident was on transmission based droplet precautions. The STNA then indicated there were no cleaning wipes available in the personal protective equipment (PPE) cart outside Resident #62's room. 365620 Page 33 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0880 Review of the CDC recommendations titled Strategies for Optimizing the Supply of Eye Level of Harm - Minimal harm or potential for actual harm Protection updated 09/13/21 revealed when manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider: Residents Affected - Many While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA approved hospital disinfectant solution. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue. Fully dry (air dry or use clean absorbent towels). Remove gloves and perform hand hygiene. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility. 5. On 10/18/21 at 12:03 P.M. observation of the lunch meal revealed STNA #245 delivered a meal tray to Resident #25's room. The resident was observed to be on transmission based droplet precautions due to displaying respiratory symptoms. The STNA exited the resident's room wearing an N95 mask, face shield and disposable gown to request a drink for the resident from another STNA. An interview on 10/18/21 at 12:03 P.M. with STNA #245 confirmed she stepped out in to the hallway without properly removing the PPE gown she was wearing. 6. On 10/18/21 at 12:20 P.M. STNA #245 was observed entering Resident #329's room. Resident #329 was on transmission based droplet precautions due to being a new admission to the facility. The STNA was observed wearing an N95 mask, face shield and disposable gown. The STNA entered the room without first applying gloves. An interview on 10/18/21 at 12:21 P.M. with STNA #245 confirmed she had entered Resident #329's without gloves as she indicated there were no gloves in the PPE cart outside of the resident's room that fit her. The STNA then informed the nurse of the need for larger gloves on the PPE cart. 7. On 10/20/21 at 8:05 A.M. observation of Resident #70 room revealed a soiled incontinence brief (Depend), wet with a strong odor was observed directly on the floor beside the bed of Resident #70. An interview on 10/20/21 at 8:06 A.M. with Resident #70 revealed she could smell the odor but did not know how or when the soiled Depend was put on the floor. An interview on 10/20/21 at 8:08 A.M. with STNA #67 confirmed the soiled depend was directly on the 365620 Page 34 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many floor beside Resident #70's bed. STNA #67 then removed the soiled Depend from the floor and discarded it properly. The STNA did not state how or why the incontinence brief was directly on the floor. 3. Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including enterolcolitis due to clostridium difficile, hypertension, obstructive and reflux uropathy, chronic obstructive pulmonary disease, type two diabetes mellitus, and muscle wasting and atrophy. Review of the admission MDS 3.0 assessment, dated 09/14/21 revealed Resident #75 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14. This resident was assessed to require extensive assistance from two staff members for toileting, bed mobility and transfers. Review of the care plan, dated 09/30/21 revealed Resident #75 had an infection of the gastrointestinal tract. Interventions included contact isolation, maintain precautions as indicated and record temperature as clinically indicated. Review of the physician's orders, dated 09/30/21 revealed an order for contact isolation related to clostridium difficile (C-Diff). On 10/18/21 at 12:05 P.M. Human Resource Director (HRD) #640 was observed to remove the lunch tray for Resident #75 from the meal cart, walked into the room of Resident #75 wearing only a surgical mask and face shield, delivered and set up the meal tray for Resident #75, then returned to her office. Interview with HRD #640 on 10/18/21 at 12:38 P.M. verified she had entered the room of Resident #75 and set up his lunch meal tray only wearing a surgical mask and face shield. HRD #640 revealed she performed hand hygiene with alcohol based hand santizer located by the resident's door on her way out of the room. Review of information from the mayoclinic (www.mayoclinic.org) related to C-Diff dated 08/27/21 revealed health care workers should practice good hand hygiene before and after treating each person in their care. In the event of a C. Diff outbreak, using soap and warm water was a better choice for hand hygiene, because alcohol-based hand sanitizers did not effectively destroy C. Diff spores. The information also indicated health care workers and visitors should wear disposable gloves and isolation gowns while in the room. 365620 Page 35 of 36 365620 10/25/2021 Riverview Post Acute 7743 County Road 1 South Point, OH 45680

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and facility policy and procedure review the facility failed to ensure laboratory testing was obtained for Resident #61 as ordered by the physician to ensure proper and justified use of antibiotic treatment for a urinary tract infection. This affected one resident (#61) of six residents reviewed for laboratory testing and unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #61's medical record revealed an admission date of 09/10/21 with the admitting diagnoses of displaced spiral fracture of shaft of right femur, COVID-19, symbolic dysfunction, difficulty in walking, hypertension, gastro-esophageal reflux disease, hypothyroidism, major depressive disorder, neuromuscular dysfunction of bladder and muscle weakness. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/17/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The assessment indicated the resident had no natural teeth or fragments. The resident received oxygen therapy. Review of the progress note, dated 9/18/2021 at 8:22 P.M. revealed new orders were received to obtain a urine specimen on 09/19/20, get a urinalysis and a culture and sensitivity (UA/C&S) on 09/20/21 and start Cipro (a medication used to treat infection) 500 milligrams (mg) twice daily for three days. Review of the resident's September 2021 Medication Administration Record (MAR) revealed the resident received a dose of Cipro 500 mg by mouth on 09/18/21 and twice daily on 09/19/21, 09/20/21 and 09/21/21. Review of the resident's medical record failed to provide UA/C&S results for the resident. On 10/20/21 at 1:27 P.M. interview with Interim Director of Nursing (IDON) #325 verified the UA/C&S was not completed and resulted in the antibiotic being administered to the resident without proper/adequate justification. Review of the facility policy titled Antibiotic Stewardship, dated 09/2017 revealed the antibiotic stewardship program would assist centers to manage and ensure the appropriate use of antibiotics while minimizing resistance to unnecessary antibiotic therapy. 365620 Page 36 of 36