Health inspection·May 10, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the facility failed to ensure resident wishes for life saving procedures were clearly designated in the medical record. This affected one resident (Resident #31) of 31 residents reviewed for advance directives. The census was 69. Findings include: Review of Resident #31's medical record revealed diagnoses including cerebral infarction, multiple sclerosis, history of traumatic brain injury, chronic obstructive pulmonary disease and depression. A plan of care dated 09/17/20 indicated Resident #31 was a full code (the facility staff will provide emergent measures in an attempt to resuscitate the resident. It may involve chest compressions, electrical shocks, and emergency medications that act to temporarily keep blood moving to essential organs). An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 was cognitively intact. A physician order dated 04/18/23 indicated a code status of Do Not Resuscitate Comfort Care (DNRCC) (permits comfort care only both before and during a cardiac or respiratory arrest. Resuscitative therapies will not be administered prior to an arrest). A signed DNR order form dated 04/20/23 indicated an order for DNRCC-Arrest (DNRCC-A) (resuscitative therapies will be administered before an arrest but not during an arrest). On 05/08/23 at 10:20 A.M., Licensed Practical Nurse (LPN) #126 verified the order in the electronic health record did not match the signed DNR order form. LPN #126 stated Resident #31 had been ill and changed his code status a couple times so it must not have been updated in the electronic health record. LPN #126 spoke to Resident #31 upon discovering the discrepancy and confirmed his wish was for a DNRCC-A. Review of the facility's Code Status Policy, with an implementation date of 01/18, indicated a DNRCC order permitted comfort care only both before and during a cardiac or respiratory arrest. Resuscitative therapies would not be administered prior to an arrest. A DNR Comfort Care -Arrest included activating the DNR protocol at the time of a cardiac or respiratory arrest. Resuscitative therapies would be administered before an arrest but not during an arrest. A copy of the DNR order was to be sent to pharmacy to be included on the routine monthly physician orders. The Social services department was responsible for reviewing the code status with the resident/responsible party on at least an annual basis to determine if there had been a change in their preferences regarding the code status. Page 1 of 24 365696 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure Resident #59 was invited to participate in care plan conferences and failed to ensure the resident's activity interests had not changed since admission and the activity program provided was meeting the resident's individual needs. This affected one resident (Resident #59) of two residents reviewed for involvement in care planning. The census was 69. Findings include: Review of Resident #59's medical record revealed diagnoses including Parkinson's disease, protein-calorie malnutrition, anxiety disorder, type two diabetes mellitus with diabetic nephropathy (diabetic kidney disease), sleep apnea, hypertension, and depression. a. On 05/07/23 at 11:28 A.M., Resident #59 stated she had not been informed of any care plan/conference meetings. Documentation revealed a care conference was held 08/18/22 with Resident #59 and responsible party attending. A care conference was held 11/09/22 with the responsible party attending. There was no evidence Resident #59 was informed of or invited to the care conference on 11/09/22 or any other conferences since. On 05/08/23 at 11:31 A.M., Social Service Designee (SSD) #106 stated the facility provided quarterly care conferences and she sent notices to responsible parties. An additional interview at 2:11 P.M. with SSD #106 revealed she usually sent care conference invitations to Resident #59's son but he did not get the notice until a week after the care conference. When asked how residents were notified of care conferences, SSD #106 provided no direct response. SSD #59 indicated she had spoken to Resident #59 multiple times but she did not document when residents or families were informed of care conferences. b. On 05/07/23 at 11:16 A.M., interview with Resident #59 revealed a lack of activities on weekends, stating she would like to see at least one activity in the afternoon that she was interested in to pass the time. An Activities assessment dated [DATE] indicated Resident #59 was Catholic by faith. Resident #59 verbalized an interest in activities during her stay. Interests included bingo, cards, crafts, church services, and trivia. Main leisure activities prior to admission included watching television and activities at the assisted living facility. Resident #59 had been in activities little time due to being on isolation. A plan of care initiated 08/16/22 indicated Resident #59 was minimally involved in the life of the facility and demonstrated limited social interaction. There was no evidence of Resident #59 being re-evaluated since admission to determine if her interests had changed or if her activity needs were being met. Review of activity participation logs from February 2023 to April 2023 revealed 11 weekend days with no activity participation. The activity participation logs revealed Resident #59 did not participate much in group activities Most of her activity participation was self-directed and included exercise, family visits, television, snacks, social interaction, and word puzzles. 365696 Page 2 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An admission Minimum Data Set (MDS) assessment dated [DATE] indicated it was very important for Resident #59 to do things with groups of people and to do favorite activities. A quarterly MDS dated [DATE] indicated Resident #59 was cognitively intact, able to understand others and able to make herself understood. On 05/08/23 at 4:09 P.M., Activity Director #124 indicated Resident #59's activity participation was dependent on her therapy schedule and personal preference. Resident #59 tended to sleep late so her participation was greater in the afternoon. Activity Director #124 stated the activity calendars were reviewed during resident council meetings and no residents had complained about weekend activities. Church was provided every Sunday afternoon but not Catholic services. On 5/9/23 at 2:58 P.M., Activity Director #124 verified she had found no activity assessments/evaluations since the admission assessment. On 05/09/23 at 9:09 A.M., Licensed Practical Nurse (LPN) #126 stated Resident #59 generally did not go to church Sunday afternoon. She was uncertain if it was because Resident #59 did not like the preacher or if it was because it was not Catholic services. LPN #126 stated the activities were repetitive at times and Resident #59 was not interested in some of the activities because she was alert and oriented so some of the activities were not stimulating for her. Resident #59 also had periods of increased anxiety where she preferred to sleep. On 05/09/23 at 10:40 A.M., Resident #59 stated she only liked one of the preachers that visited the facility to offer church services as the facility rotated preachers. She tried to go to that church service. Resident #59 stated she did like some group activities but she often was unable to participate because the activities were scheduled the same time as therapy. Review of the Resident Council Minutes from 04/2022 through 04/2023 revealed council met monthly with Resident #59 attending during the 02/2023 meeting. The meeting minutes did not support the lack of weekend activities voiced during council. 365696 Page 3 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

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 interview, record review and policy review the facility failed to ensure showers were provided as scheduled and per resident preference. This affected five Residents (#2, #16, #52, #56, and #278) of five residents reviewed for activities of daily living. The facility census was 69. Residents Affected - Some Findings included: 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, unspecified heart failure, essential hypertension and chronic gout. Review of Resident #2's annual MDS 3.0 assessment, dated 08/10/22, revealed it was very important for her to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident #2's plan of care, dated 08/12/21, revealed her hygiene preference was a shower and the resident would maintain cleanliness. Interventions included offer shave and nail trim on shower days and as needed and shower once weekly when off isolation per request. Further review of Resident #2's plan of care, dated 08/12/21, revealed she had an alteration in activities of daily living (ADL) performance and participation related to history of cerebral vascular accident, hemiplegia, weakness, anemia, and congestive heart failure. Goals included resident needs will be met with regard to activities of daily living. Interventions included encourage activity during daily care and encourage resident participation while performing activities of daily living. Review of the shower schedules for the North Hall (100 hall) revealed Resident #2 was to receive showers on Wednesdays and Saturdays. Review of Resident #2's scheduled bathing documentation in State Tested Nursing Assistant (STNA) documentation from 04/08/23 to 05/07/23 revealed she received a shower on 04/12/23 (Wednesday) and 04/15/23 (Saturday). Review of her as needed bathing documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. Review of Resident #2's paper Bathing and Skin Reports, dated 02/04/23 to 05/07/23 revealed she received bathing on the following dates: 02/04/23 (shower on Saturday), 02/08/23 (type not documented on Wednesday), 02/15/23 (shower on Wednesday), 02/22/23 (shower on Wednesday), 03/01/23 (type not documented on Wednesday), 03/04/23 (shower on Saturday), 03/15/23 (bed bath on Wednesday, refused shower), 03/18/23 (shower on Saturday), 03/25/23 (shower on Saturday), 04/01/23 (shower on Saturday), 04/12/23 (shower on Wednesday), 04/15/23 (shower on Saturday), and 04/26/23 (type not documented on Wednesday) and refused showers on 04/05/23 (Sunday). Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed she was cognitively intact, personal hygiene activity occurred only once or twice during the look back period, she needed supervision with setup help for transfers, and needed limited assistance of one person to physically assist with dressing. Further review of the assessment revealed Resident #2 did not exhibit any rejection of care behavior. 365696 Page 4 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/07/23 at 11:04 A.M. with Resident #2 revealed there were not enough staff, and she did not get her showers like she was supposed to. She reported she did not get them twice a week and sometimes not every week. Interview on 05/07/23 at 12:18 P.M. with Registered Nurse (RN) #175 revealed due to a lack of staff, residents were not receiving baths/showers and their clothes were not being changed as they should be. Interview on 05/07/23 at 12:32 P.M. with Licensed Practical Nurse (LPN) #173 revealed staffing was short and residents were not getting their showers like they should. The LPN reported that through the week there is only one STNA to shower residents and she does not always get to provide showers as she is pulled to work the floor or transport residents to appointments. Interview on 05/08/23 at 11:55 A.M. with the Director of Nursing (DON) verified showers were not provided as requested or preference for Resident #2. She verified not having enough staff in the building was a concern as residents were not receiving assistance with ADLs, such as showers. 2. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including quadriplegia, personal history of traumatic brain injury, chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity and need for assistance with personal care. Review of Resident #16's annual MDS 3.0 assessment, dated 01/25/23, revealed it was very important to her to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #16's plan of care, dated 03/09/20, revealed her hygiene preference was a shower and the resident would maintain cleanliness. Interventions included offer to shave and trim nails on shower day. The resident would like to maintain right to refuse and receive grooming per preference. Shower twice weekly per request; Resident would like to maintain right to refuse showers and receive bed bath in place. Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/10/23, revealed she was cognitively intact and needed supervision with setup help only bed mobility, transfer and hygiene. Further review of the assessment revealed rejection of care behavior was not exhibited. Review of the shower schedules for the North Hall (100 hall) revealed Resident #16 was to receive showers on Mondays and Thursdays. Review of Resident #16's scheduled bathing and bathing as needed documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. Review of Resident #16's paper Bathing and Skin Reports, dated 02/06/23 to 05/07/23 revealed she received bathing on the following dates: 02/06/23 (shower on Monday), 02/16/23 (shower on Thursday), 02/20/23, (shower on Monday), 02/23/23 (shower on Thursday), 03/02/23 (shower Thursday), 03/08/23 (shower on Wednesday), 03/09/23 (shower on Thursday), 03/13/23 (shower on Monday), 03/16/23 (bed bath on Thursday, refused shower), 03/20/23 (shower on Monday), 03/23/23 (shower on Thursday), 03/30/23 (shower on Thursday), 04/03/23 (type not specified on Monday), 04/15/23 (shower on Saturday), 04/17/23 (shower on Monday) and 04/27/23 (bed bath on Thursday, refused shower) and there was no documentation of refusing of bathing. 365696 Page 5 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/07/23 at 12:14 P.M. with Resident #16 revealed she did not get showers like she should and was unsure of the reason. Interview on 05/07/23 at 12:18 P.M. with RN #175 revealed there was not enough staff to meet the needs of the residents. RN #175 reported there were only enough staff to feed residents, make sure residents are dry (for incontinence), and medications were administered. She reported residents are not getting bathed and their clothes are not being changed as they should be. Interview on 05/07/23 at 12:32 P.M. with LPN #173 revealed residents were not getting their showers like they should be. She reported that through the week there was one shower STNA. However, she doesn't always get to provide showers because she got pulled to the floor to work if needed and sometimes was pulled for transporting of residents to appointments. Interview on 05/08/23 at 11:55 A.M. with the DON verified showers were not provided as requested or preference for Resident #16. 3. Review of Resident #52's medical record revealed a re-admission on [DATE] with diagnoses including polyosteoarthritis, essential hypertension, and asthma. Review of Resident #52's plan of care, dated 01/20/22, revealed a risk for decline in ADL function related to impaired mobility, impaired balance, increased weakness and obesity. Goals included resident needs will be met with regard to activity of daily living. Interventions included encourage resident participation while performing activities of daily living. Review of Resident #52's annual MDS 3.0 assessment, dated 01/01/23, revealed it was very important to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/03/23, revealed she was cognitively intact, required extensive assistance of one person for bed mobility and personal hygiene, and activities of transfer and dressing occurred only once or twice during the look back period. Further review of the assessment revealed Resident #52 did not reject care. Review of Resident #52's plan of care, with a review date of 04/03/23, revealed her hygiene preference was a shower and the resident would maintain cleanliness. Interventions included offer shave and nail trim on shower days and as needed and shower once weekly and as needed. Review of the shower schedules for the North Hall (100 hall) revealed Resident #52 was to receive showers on Mondays and Thursdays. Review of Resident #52's paper Bathing and Skin Reports, dated 02/04/23 to 05/07/23 revealed she received bathing on the following dates: 02/05/23 (shower on Sunday), 02/20/23 (shower on Monday), 02/27/23 (shower on Monday), 03/06/23 (shower on Monday), 03/13/23 (shower on Monday), 03/20/23 (shower on Monday), 03/30/23 (bed bath Thursday), 04/02/23 (bed bath on Sunday), 04/03/23 (shower on Monday), 04/16/12 (shower on Sunday) and 05/01/23 (shower on Monday) and refused showering on 02/04/23 (Saturday) and 02/23/23 (Thursday). Review of Resident #52's scheduled bathing and bathing as needed documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. 365696 Page 6 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/07/23 at 10:52 A.M. with Resident #52 revealed there were not enough staff in the facility to provide care. She reported she was supposed to get showers everyone Monday and Thursdays and she did not. Resident #52 reported sometimes she went two weeks without a shower. Interview on 05/07/23 at 12:18 P.M. with RN #175 reported there were only enough staff to feed residents, make sure residents are dry (for incontinence), and medications were administered. She reported residents are not getting bathed and their clothes are not being changed as they should be. Interview on 05/07/23 at 12:32 P.M. with LPN #173 revealed residents are not getting their showers like they should be. She reported that throughout the week there is one shower STNA. However, she doesn't always get to provide showers because she gets pulled to the floor to work if needed and sometimes is pulled for transporting of residents to appointments. Interview on 05/08/23 at 11:55 A.M. with the DON verified showers were not provided as requested or preference for Resident #52. 4. Review of Resident #56's medical record revealed an admission on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, progressive supranuclear ophthalmoplegia (unable to move eyes at will especially upward), and hyperlipidemia. Review of Resident #56's plan of care, dated 04/05/22, revealed her hygiene preference was a shower and the resident would maintain cleanliness. Interventions included offer shave and nail trim on shower days and as needed and shower once weekly and as needed. Review of Resident #56's plan of care, dated 04/05/22, revealed she had an ADL self-care performance deficit related to hemiplegia, impaired balance, limited mobility, limited range of motion, obesity, dysphagia, and progressive supranuclear ophthalmoplegia. Interventions included monitor, document, and report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Review of Resident #56's annual Minimum Data Set (MDS) 3.0 assessment, dated 04/11/23, revealed she was cognitively intact, needed extensive assistance of one person for bed mobility, needed supervision with set up only for transfers, needed supervision with one person to assist with dressing and personal hygiene. Further review of the assessment revealed Resident #56 did not reject care and it was very important to her to choose between a tub bath, shower, bed bath, or sponge bath. Review of the shower schedules for the North Hall (100 hall) revealed Resident #56 was to receive showers on Monday and Thursdays. Review of Resident #56's paper Bathing and Skin Reports, dated 02/16/23 to 05/07/23 revealed she received bathing on the following dates: 02/16/23 (type not identified on Thursday), 02/20/23 (shower on Monday), 03/02/23 (shower on Thursday), 03/06/23 (shower on Monday), 03/16/23 (shower on Thursday), 03/23/23 (shower on Thursday), 03/30/23 (shower on Thursday), 04/03/23 (shower on Monday), 04/16/23 (shower on Sunday) and 04/27/23 (shower on Thursday) and refused showering on 02/23/23 (Thursday). Review of Resident #56's scheduled bathing and bathing as needed documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. 365696 Page 7 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 05/07/23 at 11:56 A.M. with Resident #56 revealed she was not getting her showers like she was supposed to. Interview on 05/07/23 at 12:18 P.M. with RN #175 revealed She reported residents are not getting bathed and their clothes are not being changed as they should be. Residents Affected - Some Interview on 05/07/23 at 12:32 P.M. with LPN #173 revealed residents are not getting their showers like they should be. She reported that throughout the week there is one shower STNA. However, she did not always get to provide showers because she gets pulled to the floor to work if needed and sometimes is pulled for transporting of residents to appointments. Interview on 05/08/23 at 11:55 A.M. with the DON verified showers were not provided as requested or preference for Resident #56. 5) Review of Resident #278 medical record revealed Resident #278 was admitted to facility on 03/26/23 with admitting diagnoses including sepsis, dementia, altered mental status, depression, and diabetes mellitus type II. Review of Resident #278 base line care plan dated 03/26/23 revealed Resident #278 required staff assistance with bathing. Review of Resident #278 Activities of Daily Living (ADL) care performance deficit care plan dated 03/27/23 revealed Resident #278 required staff assistance with bathing as needed. Review of Resident #278 admission Minimum Data Sheet (MDS) dated [DATE] Section G Functional Status question G0110 revealed Resident #278 required extensive assistance of one person to complete personal hygiene. Further review of question G0120 revealed bathing did not occur during the seven days look back period prior to completion of the admission MDS. Review of shower schedule for South Hall (200 hall) revealed Resident #278 to receive showers or bathing on Fridays. Review of Resident #278 staff bathing and skin assessment form dated 03/31/23 revealed Resident #278 received a bed bath performed by therapy. Further investigation of Resident #278 bathing and skin assessment forms dated 04/07/23 and 04/23/23 reveled Resident #278 received a shower with assistance from staff. There were no further bathing and skin assessment forms completed for Resident #278 scheduled shower or bathing days of Friday dated 04/14/23, 04/28/23, 05/05/23. There were no bathing and skin assessment forms for bathing completed as needed by staff. Review of Resident #278 staff computer documentation system point of care (POC), revealed the section for scheduled bathing had no documentation entered by staff for the past 30 days (04/08/23 to 05/08/23). Further review of Resident #278 POC revealed the section for bathing as needed (PRN) had no documentation entered by staff for the past 30 days (04/08/23 to 05/08/23). Interview on 05/07/23 at 11:30 A.M. with Resident #278 revealed he had only received one or two showers since being admitted . Interview on 05/08/23 at 11:30 AM with Licensed Practical Nurse (LPN) # 126 revealed staff reviews the shower schedule at the beginning of their shift for the specific day. They then record the 365696 Page 8 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents who are to receive a shower or bath on their assignment sheets. The staff completes the bathing and skin assessment form and documents in Point of Care (POC) following completion of the task. The completed forms are then given to the Director of Nursing for filing. Interview on 05/08/23 at 11:57 AM with Director of Nursing (DON) confirmed Resident #278 has not received a shower or bath since 04/23/23 and there was no documentation to confirm shower or bathing had been completed as needed by staff. DON confirmed the lack of documentation and completion of shower or bathing task for Resident #278 is due to the decrease in direct care staff in the facility. Review of the facility policy titled, Activities of Daily Living Policy, revised 01/22, revealed it is the policy of this facility that each resident will have their ADL needs determined within seven days of admission, then will have an individualized plan of care to guide staff in delivering the necessary ADL support and care. ADL services are directed toward the goal of promoting the highest practicable physical, mental, and psychosocial functioning of the resident. 365696 Page 9 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to ensure activities were provided on the weekends to meet the resident needs. This affected one resident (Resident #9) of two residents reviewed for activities. The facility census was 69. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 06/25/19 with diagnoses including unspecified dementia, weakness, attention and concentration deficit, and tremors. Review of Resident #9's plan of care, dated 07/09/19, revealed she was at risk for a decline in her activities of daily living function related to decreased mobility, weakness, and tremors. Interventions included provide physical assistance with oral hygiene and teeth brushing due to tremors. Review of Resident #9's plan of care, dated 07/19/19, revealed she had an alteration in activity participation related to behaviors, impaired decision making, and impaired mobility. She needed assistance to activities. Interventions included arrange for activity aide to visit and encourage resident to observe or designate activity, familiarize resident with nursing home environment and activity programs on a regular basis, give resident an opportunity to express opinion of activities attended, and post persona activity schedule in resident's room. Review of the facilities activities calendar for February, March and April 2023 revealed on Saturdays 02/11/23, 02/25/23, 03/11/23 03/25/23, 04/08/23, and 04/09/23 was puzzle packs and coloring sheets located in the folder on the bulletin board, on Sundays 02/12/23, 02/26/23, 03/12/23, 03/26/23, puzzle packs ad coloring sheets and at 2:00 P.M. church services. Review of Resident #9's activity participation documentation revealed for February 2023 she was active in one-to-one activities three times, in group programs 22 times, and self-directed programs 25 times, for March 2023 she was active in one-to-one activities six times, group programs 21 times, and self-directed programs 21, and for April 2023 she was active in one-to-one activities seven times, group activities 19 times, and self-directed programs 21 times. Further review of the documentation revealed she participated a total of ten days in group programs activities and self-directed programs out of 24 weekend days. Review of Resident #9's Activities Assessment, dated 03/18/23, revealed she had partial use of her right and left hand function which had an impact on activities. Review of Resident #9's annual Minimum Data Set (MDS), dated [DATE], revealed she was cognitively intact. Further review revealed it was very important to have books, newspapers, and magazines to read, listen to music she liked, be around animals such as pets, keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. Interview on 05/07/23 at 10:05 A.M. with Resident #9 revealed activities offered weekend activities she cannot do. She reported they offer art, and she cannot do it with her tremors. She reported there was not much to do on every other Saturday or Sunday because they have self-directed activities like coloring, but she cannot do coloring because of her tremors. 365696 Page 10 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0679 Level of Harm - Minimal harm or potential for actual harm Observation on 05/07/23 at 2:00 P.M. of church services and no other scheduled group programs for the day. Observation on 05/08/23 at 10:07 A.M. of Bible Study activity in the main common area with five residents in attendance. Resident #9 was in attendance. Residents Affected - Few Interview on 05/09/23 at 8:37 A.M. with Activities Director #124 revealed there were no activity staff in the facility every other weekend. She reported that there were puzzles, games, coloring sheets, and puzzle sheets (word searches, etc.) put out for the weekends that residents can do the activity. AD #124 reported there were church services every Sunday even if activity staff was not in the building. She revealed the aides were good at getting the residents to the service. AD #124 verified Resident #9 had tremors and could not do activities which required fine motor skills. She reported on the weekends when activity staff was not in the building, Resident #9 could read because she was able to turn the pages. She verified there would be no activities for Resident #9 other than reading, socializing and church services on Saturday and Sunday when no activity staff were in the facility. Review of the facility policy titled, Activities Policy, revised 04/22, revealed the center strives to provide meaningful experiences that benefit the resident psychologically, socially, spiritually, and physically through activities across all ages regardless of the resident's cognitive abilities and physical limitations. This can be a challenge as every individual has different interests. 365696 Page 11 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to maintain adequate staffing levels to provide bathing for residents. This affected five residents (Residents #2, #16, #52, #56 and #278) of five residents reviewed for bathing with the potential to affect all 69 residents. The facility census was 69. Findings include: On 05/07/23 at 8:30 A.M. the survey team entered the facility to conduct the annual survey. There were four licensed nurses and one State Tested Nursing Assistant (STNA) on duty to provide care for 69 residents currently residing in the facility. 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of the shower schedules for the North Hall (100 hall) revealed Resident #2 was to received showers on Wednesdays and Saturdays. Review of Resident #2's scheduled bathing documentation in STNA documentation from 04/08/23 to 05/07/23 revealed she received a shower on 04/12/23 and 04/15/23. Review of Resident #2 as needed bathing documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed she was cognitively intact, personal hygiene activity occurred only once or twice during the look back period and needed limited assistance of one person to physically assist with dressing. Further review of the assessment revealed Resident #2 did not exhibit any rejection of care behavior. Interview on 05/07/23 at 11:04 A.M. with Resident #2 revealed there were not enough staff, and she didn't get her showers like she was supposed to. She reported she didn't get them twice a week and sometimes not every week. 2. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including quadriplegia, personal history of traumatic brain injury, chronic embolism, and thrombosis of other specified deep vein of unspecified lower extremity and need for assistance with personal care. Review of the shower schedules for the North Hall (100 hall) revealed Resident #16 was to received showers on Mondays and Thursdays. Review of Resident #16's paper Bathing and Skin Reports, dated 02/06/23 to 05/07/23 revealed she received bathing on the following dates: 02/06/23 (shower on Monday), 02/16/23 (shower on Thursday), 02/20/23, (shower on Monday), 02/23/23 (shower on Thursday), 03/02/23 (shower Thursday), 03/08/23 (shower on Wednesday), 03/09/23 (shower on Thursday), 03/13/23 (shower on Monday), 03/16/23 (bed bath on Thursday, refused shower), 03/20/23 (shower on Monday), 03/23/23 (shower on Thursday), 03/30/23 365696 Page 12 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (shower on Thursday), 04/03/23 (type not specified on Monday), 04/15/23 (shower on Saturday), 04/17/23 (shower on Monday) and 04/27/23 (bed bath on Thursday, refused shower) and there was no documentation of refusing of bathing. Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/10/23, revealed she was cognitively intact and needed supervision with setup help only bed mobility, transfer, and hygiene. Further review of the assessment revealed rejection of care behavior was not exhibited. Interview on 05/07/23 at 12:14 P.M. with Resident #16 revealed she did not get showers like she should. She was not sure if it was because of low staffing but she wasn't receiving them as she should. 3. Review of Resident #52's medical record revealed an admission on [DATE] with diagnoses including polyosteoarthritis, essential hypertension, and asthma. Review of Resident #52's paper Bathing and Skin Reports, dated 02/04/23 to 05/07/23 revealed she received bathing on the following dates: 02/05/23 (shower on Sunday), 02/20/23 (shower on Monday), 02/27/23 (shower on Monday), 03/06/23 (shower on Monday), 03/13/23 (shower on Monday), 03/20/23 (shower on Monday), 03/30/23 (bed bath Thursday), 04/02/23 (bed bath on Sunday), 04/03/23 (shower on Monday), 04/16/12 (shower on Sunday) and 05/01/23 (shower on Monday) and refused showering on 02/04/23 (Saturday) and 02/23/23 (Thursday). Review of Resident #52's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/03/23, revealed she was cognitively intact, required extensive assistance of one person for bed mobility and personal hygiene, and activities of transfer and dressing occurred only once or twice during the look back period. Further review of the assessment revealed Resident #52 did not reject care. Review of the shower schedules for the North Hall (100 hall) revealed Resident #52 was to received showers on Mondays and Thursdays. Review of Resident #52's scheduled bathing and bathing as needed documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. Interview on 05/07/23 at 10:52 A.M. with Resident #52 revealed there were not enough staff in the facility to provide care. She reported she was supposed to get showers everyone Monday and Thursdays and she did not. Resident #52 reported sometimes she went two weeks without a shower. 4. Review of Resident #56's medical record revealed an admission on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, progressive supranuclear ophthalmoplegia, and hyperlipidemia. Review of Resident #56's paper Bathing and Skin Reports, dated 02/16/23 to 05/07/23 revealed she received bathing on the following dates: 02/16/23 (type not identified on Thursday), 02/20/23 (shower on Monday), 03/02/23 (shower on Thursday), 03/06/23 (shower on Monday), 03/16/23 (shower on Thursday), 03/23/23 (shower on Thursday), 03/30/23 (shower on Thursday), 04/03/23 (shower on Monday), 04/16/23 (shower on Sunday) and 04/27/23 (shower on Thursday) and refused showering on 02/23/23 (Thursday), Review of Resident #56's scheduled bathing and bathing as needed documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. 365696 Page 13 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0725 Level of Harm - Minimal harm or potential for actual harm Review of the shower schedules for the North Hall (100 hall) revealed Resident #56 was to received showers on Monday and Thursdays. Review of Resident #56's scheduled bathing and bathing as needed documentation in STNA documentation from 04/08/23 to 05/07/23 revealed no documented showers were provided. Residents Affected - Many Review of Resident #56's annual Minimum Data Set (MDS) 3.0 assessment, dated 04/11/23, revealed she was cognitively intact, needed extensive assistance of one person for bed mobility, needed supervision with set up only for transfers, needed supervision with one person to assist with dressing and personal hygiene. Further review of the assessment revealed Resident #56 did not reject care and it was very important to her to choose between a tub bath, shower, bed bath, or sponge bath. Interview on 05/07/23 at 11:56 A.M. with Resident #56 revealed she was not getting her showers like she was supposed to. 5. Review of Resident #278 medical record revealed Resident #278 was admitted to facility on 03/26/23 with admitting diagnoses including sepsis, dementia, altered mental status, depression, and diabetes mellitus type 2. Review of Resident #278 base line care plan dated 03/26/23 revealed Resident #278 required staff assistance with bathing. Review of Resident #278 Activities of Daily Living (ADL) care performance deficit care plan dated 03/27/23 revealed Resident #278 requires staff assistance with bathing as needed. Review of shower schedule for South Hall (200 hall) revealed Resident #278 to receive showers or bathing on Fridays. Review of Resident #278 staff bathing and skin assessment form dated 03/31/23 revealed Resident #278 received a bed bath performed by therapy. Further investigation of Resident #278 bathing and skin assessment forms dated 04/07/23 and 04/23/23 revealed Resident #278 received a shower with assistance from staff. There were no bathing and skin assessment forms for bathing completed as needed by staff. Resident #278 admission Minimum Data Sheet (MDS) dated [DATE] Section G Functional Status question G0110 revealed Resident #278 required extensive assistance of one person to complete personal hygiene. Further review of question G0120 revealed bathing did not occur during the look back period prior to completion of the admission MDS. Interview on 05/07/23 at 11:30 A.M. with Resident #278 revealed he had only received one or two showers since being admitted . He wasn't sure if it was because of staffing. 6. Interview on 05/07/23 at 12:18 P.M. with Registered Nurse (RN) #175 revealed there was not enough staff to meet the needs of the residents. She reported the residents are suffering and don't deserve not to get the care they need. RN #175 reported there were only enough staff to feed residents, make sure residents are dry (for incontinence), and medications were administered. She reported residents are not getting bathed and their clothes are not being changed as they should be. 7. Interview on 05/07/23 at 12:32 P.M. with Licensed Practical Nurse (LPN) #173 revealed staffing 365696 Page 14 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0725 Level of Harm - Minimal harm or potential for actual harm was short and the State Tested Nursing Assistants (STNAs) get overwhelmed when the facility is short staffed. She reported there was not enough staff to meet all the residents' needs. She reported residents were not getting their showers like they should be. She reported that through the week there was one shower STNA. However, she doesn't always get to provide showers because she got pulled to the floor to work if needed and sometimes was pulled for transporting of residents to appointments. Residents Affected - Many 8. Interview on 05/07/23 at 3:30 P.M. with a staff member who wished to remain anonymous revealed she able to get the basic care needs completed for residents only because the nurse was able to help her complete the tasks. She stated she did not have time to complete showers due to being the only STNA working South Hall (200 hall). 9. Interview on 05/08/23 at 1:30 P.M. with Licensed Practical Nurse #126 revealed staff attempts to complete assigned tasks. She reports there's not enough staff to meet the needs of the residents. She reports she tries to help the staff but when she does then she has a hard time completing her nursing tasks. 10. Interview on 05/09/23 at 12:58 P.M. with Resident Assistant (RA) #121 reveals she can only pass ice water, pass meal trays and answer call lights but can not do any direct resident care. She reports she helps the staff as best she can within her job limitations. She reports the direct care staff have a hard time getting their jobs done due to the low staffing. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided Activities of Daily Living (ADL) information for 69 residents. The ADL information revealed the facility had zero residents independent with bathing, zero residents independent with dressing, zero residents independent with transfers, zero residents independent with toilet use and 65 residents independent with eating. The facility identified 57 residents who required the assist of one or two staff for bathing and 12 residents who were totally dependent on staff. The facility identified 61 residents who required assist of one or two staff for dressing and eight residents who were totally dependent on staff. The facility identified 63 residents who required assist of one or two staff for transfers and six residents who were totally dependent on staff. The facility identified 56 residents who required assist of one or two staff for toilet use and 13 residents who were totally dependent on staff. The facility identified one resident who required assist of one or two staff for eating and three residents who were totally dependent on staff. Review of staffing schedule for the week of 05/7/23 to 05/13/23 revealed there were three to five nurses on day shift and two to four nurses on night shift. There were two to five State Tested Nursing Assistants (STNA) on day shift and two to four STNAs on night shift. Review of the Facility Assessment updated 05/01/23 reveals the facility staffing plan for a minimum of two Licensed Practical Nurses (LPN) per shift, one Registered Nurse (RN) for eight hours per day, four to five State Tested Nursing Assistants (STNA) per shift. Interview on 05/08/23 at 11:55 A.M. with the Director of Nursing (DON) verified showers were not provided as requested or preference for Residents #2, Resident #16, Resident #52, Resident #56 and Resident #278. She verified not having enough staff in the building is a concern. This deficiency represent noncompliance invetigated under Complaint NumberOH00140380. 365696 Page 15 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0758 Level of Harm - Minimal harm or potential for 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** 3. Review of Resident #21's medical record revealed she was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy, acute and chronic diastolic (congestive) heart failure, generalized muscle weakness, paroxysmal atrial fibrillation, obstructive and reflux uropathy, non-pressure chronic ulcer of unspecified calf with unspecified severity, cellulitis of the right lower limb, stage 4 chronic kidney disease, depression, and anxiety. Review of Resident #21's physician orders since 11/24/22 revealed she had been ordered Zyprexa for agitation, anxiousness, aggression, and vascular dementia since her admission. Review of Resident #21's plan of care, dated 11/25/22, revealed she had a mood problem related to anxiety and depression. Interventions included administering medications as ordered. Monitor and document for side effects and effectiveness. Monitor target behaviors of tearfulness, sad affect, accusatory, agitation. Monitor, record, and report to the medical doctor as need mood patterns and signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of Resident #21's care plan, dated 11/25/22, revealed the resident has vascular dementia. Interventions included observe for and report to the nurse any changes in cognitive function, specifically changes in decision-making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Review of Resident #21's Medication Administration Records (MARs) for January 2023, February 2023, March 2023, April 2023, and May 2023, revealed she received the Zyprexa as ordered. Review of Resident #21's pharmacy recommendations, dated January 2023 through April 2023 revealed no findings or recommendations regarding Zyprexa ordered for agitation, anxiousness, aggression, or vascular dementia were not appropriate diagnosis for the use of an antipsychotic. Review of Resident #21's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed she was mildly cognitively impaired and had active diagnoses of non-Alzheimer's dementia, anxiety disorder and depression. Interview on 05/09/23 at 1:28 P.M. with the DON verified Resident #21 did not have an appropriate diagnosis for the use of Zyprexa, an antipsychotic. The DON also verified the pharmacist did not identify the lack of appropriate diagnosis during monthly medication review. Review of the facility policy titled, Antipsychotic Medication Use, dated 04/18, revealed residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Based on medical record review, policy review and interview the facility failed to ensure antipsychotic medication use was appropriate. This affected three residents (Resident #19, #21 and #67) out of five residents reviewed for unnecessary medications. The facility census was 69. Findings include: 365696 Page 16 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Review of Resident #19 medical record revealed Resident #19 was admitted to the facility on [DATE] with admitting diagnoses including encephalopathy and unspecified dementia with behavioral disturbance. Review of Resident #19 physician medication listing revealed Resident #19 was ordered on admission [DATE]) Aricept (cognition enhancing medication) 5 milligrams (mg) daily for dementia and Seroquel (antipsychotic medication) 25 milligrams (mg) twice daily for dementia with behaviors which include aggression, hitting, and yelling. On 01/21/23 the physician attempted a gradual dose reduction for Seroquel, decreasing the dosage to 12.5 mg twice daily for dementia with behaviors. Further review revealed no physician order for psychiatric services. Review of Resident #19 abnormal involuntary movement scale (AIMS) assessment completed on 01/26/23 and 04/28/23 revealed no abnormal effects with use of antipsychotic medication. Review of Resident #19 quarterly Minimum Data Sheet (MDS) dated [DATE] revealed in Section I - Active Diagnoses having dementia marked as an active diagnosis. Further review of Section N - Medications revealed use of an antipsychotic medication administered for seven days during the seven day look back period prior to completion of the MDS. Review of Resident #19 Psychotropic medication care plan dated 04/29/23 revealed the use of antipsychotic medication for behavioral disturbances. Review of Resident #19 behavioral charting on point of care, computer documentation for staff, revealed Resident #19 had behaviors on night shift dated 02/19/23 including aggression, anxiety, and yelling. Further review of behavioral charting reveals on 04/23/23 Resident #19 had behaviors including aggression, anxiety and wandering. Review of Resident #19 pharmacist recommendations dated 02/20/23 and 04/26/23 revealed no recommendations for medication changes or addressed any irregularities of #19 medication regimen review. The pharmacist did not address the use of an antipsychotic medication for dementia with behavioral disturbance. Interview on 05/09/23 at 1:15 P.M. with Director of Nursing (DON) confirmed Resident #19 received an antipsychotic medication without an appropriate diagnosis for the use of the medication. The DON also verified the pharmacist did not address the medication use through pharmacy recommendations. 2. Review of Resident #67 medical record revealed Resident #67 was admitted to the facility on [DATE] with admitting diagnoses including depression, anxiety, diabetes mellitus type 2 and hypothyroidism. Review of Resident #67 physician order listing revealed Resident #67 has ordered buspirone (antianxiety medication) 15 milligrams (mg) twice daily for anxiety and olanzapine (antipsychotic medication) 5 milligrams (mg) daily at bedtime for depression. There were no orders for psychiatric services. Review of Resident #67 abnormal involuntary movements scale (AIMS) dated 01/27/23 and 05/05/23 revealed Resident #67 had no effects of antipsychotic medication use. Review of Resident #67 admission minimum data sheet (MDS) dated [DATE] revealed in Section E Behavior there was no behaviors marked for the seven day look back period prior to completion of the 365696 Page 17 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS. Further review revealed Section I - active diagnoses with depression and anxiety as being marked as active diagnoses. Further review revealed Section N - medications with the use of antipsychotic medication marked for seven days of the seven day look back period and the use of antianxiety medication marked for seven days of the seven day look back period prior to the completion of the MDS. Review of Resident #67 Psychotic medication care plan dated 02/01/23 revealed use of antipsychotic medication with Resident #67 target behaviors including lack of interest, anxious state and being withdrawn. Review of Resident #67 pharmacist medication regimen review and recommendations dated 02/20/23 and 04/26/23 revealed the consulting pharmacist did not address irregularities in the use of olanzapine (antipsychotic medication) for the use of depression. Interview on 05/09/23 at 1:15 P.M. with Director of Nursing (DON) confirmed Resident #67 did not have an appropriate medical diagnosis for the use of an antipsychotic medication. The DON also confirmed the consulting pharmacist did not address the irregularity during monthly medication reviews. 365696 Page 18 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

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, medical record review, medication information review, interview, and policy review the facility failed to ensure the medication administration error rate was not greater than five percent. Two medication errors out of 25 opportunities were observed resulting in an eight percent medication error rate. This affected two (Residents #4 and #16) of seven residents observed for medication administration. Residents Affected - Few Findings include: 1. On 05/08/23 at 11:07 A.M., Licensed Practical Nurse (LPN) #107 was observed administering medication to Resident #16. One and one half tablets of Simethicone (used to relieve symptoms of gas) 80 milligrams (mg) was administered for a total of 120 mg. Review of the physician orders revealed simethicone 125 mg every six hours. LPN #107 verified she was administering 120 mg of simethicone as she prepared the medication prior to administration. Review of the facility's policy, Administration and Documentation of Medications (revised October 2022), revealed prior to and during administration, the nurse must observe the right dose was administered by verifying the dosage on the Medication Administration Record (MAR). Instructions revealed the physician's original order should be checked if there was a concern or question. 2. On 05/09/23 between 7:32 A.M. and 7:54 A.M., Registered Nurse (RN) #175 was observed preparing/administering medications to Resident #4. While preparing the medications, RN #175 withdrew a bottle of glargine insulin and withdrew 14 units for administration. The box indicated the vial had been opened on 04/07/23. After preparing the insulin RN #175 was asked how long the insulin could be used after being opened and she stated 30 days then looked at the date the insulin was opened for use and stated she would need to get another vial. Review of the information on the side of the box indicated the insulin should be discarded after 28 days. This information was addressed with RN #175 who verified the manufacturer indicated the insulin should be discarded after 28 days. Review of the facility's policy, Administration and Documentation of Medications (revised October 2022), revealed expiration dates of all medications must be checked prior to dispensing and administering. Once insulin was opened or removed from the refrigerator, the vial must be dated. The vial was discarded after 28 days, or as otherwise directed by the manufacturer. 365696 Page 19 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

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 Based on resident interview, observation, staff interview and policy review, the facility failed to ensure food was served at appropriate temperatures. This had the potential to affect all but one resident (Resident #4) identified as not receiving nutritional services from the dietary department. The facility census was 69. Residents Affected - Many Findings include: Interview with Resident #124 on 05/07/23 at 11:29 A.M. revealed concerns with cold food served by the facility. Test tray and food service observation on 05/09/23 revealed the following: The main course served was turkey ala king. 11:58 A.M., food tray line began in the kitchen with North Unit first cart. 12:05 P.M., test tray prepared and placed onto the North Unit cart first cart. 12:06 P.M., North Unit first cart out of the kitchen and delivered to the North Unit. 12:08 P.M., North Unit first cart arrived to the North Unit. 12:12 P.M., two staff members begin passing meal trays. 12:32 P.M., two resident meal trays (Residents #9 and #38) and test tray left in North Unit 1st cart. 12:33 P.M., staff begin passing meals trays from North Unit second cart. 12:45 P.M., last tray served from North Unit first cart to Resident #9. 12:46 P.M., test tray received. Meal consisted of puree turkey ala king and regular turkey ala king. Puree meal was luke warm and tested at 92 degrees Fahrenheit (F). Regular turkey ala king was also luke warm and tested at 90 degrees F. On 05/09/23 at 12:50 P.M. State Tested Nurse Aide (STNA) #197 verified it took an extended amount of time to finish the North Unit first cart and the food was not served at an appropriate temperature. STNA #197 indicated Resident #9 and #38 are dependent for meal assistance and are served last even though their trays are placed on the North Unit first cart. Review of the facility policy titled Food Temperature Guideline dated 04/2018 indicated hot foods should be served at a temperature range of 110-120 degrees F. 365696 Page 20 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and policy review the facility failed to ensure garbage was properly secured inside the dumpster and not lying on the ground outside the dumpster. This had the potential to affect all residents within the facility. The facility census was 69. Residents Affected - Many Findings include: Observation during the initial kitchen tour on 05/07/23 from 9:00 A.M. to 9:15 A.M. revealed two bags of trash lying on the ground next to the dumpster outside of the kitchen. Interview with the Dietary Manager (DM) #166 on 05/07/23 at 9:13 A.M. verified trash is not to be outside the dumpster and should be placed within the dumpster. Review of the facility policy Housekeeping with a review date of 04/18 indicated the dumpster are is to be kept clean at all times, free of debris, rodents and standing water. 365696 Page 21 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

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** 4. On 05/07/23 at 11:06 A.M., Resident #224 was observed lying in bed. A sign in the doorway indicated Resident #224 was on enhanced barrier precautions. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted multi-drug resistant organism or any resident with a wound or indwelling medical device during specific high-contact resident care activities. No personal protective equipment such as gowns were observed in the room. Residents Affected - Many On 05/07/23 at 12:00 P.M., Regional Clinical Director #202 was observed exiting Resident #224's room. Regional Clinical Director #202 stated unless direct care was being provided personal protective equipment did not need to be donned. Regional Clinical Director #202 stated personal protective equipment was kept in the closet or sometimes in the hall but since she did not observe any in the hall it must be kept in the closet. At 12:46 P.M. an unidentified staff member entered the hall where Resident #224 resided with isolation carts with personal protective equipment and started placing them in rooms of residents with signs for enhanced barrier precautions. Licensed Practical Nurse (LPN) #122 inquired what the carts were for and the staff member responded residents on barrier precautions were supposed to have them in place. On 05/07/23 at 12:49 P.M., LPN #122 was interviewed regarding what process was being implemented when caring for residents on enhanced barrier precautions. LPN #122 stated staff wore resident gowns over their scrubs. On 05/07/23 at 1:02 P.M., an isolation cart was placed in Resident #66's room who had signs posted for enhanced barrier precautions. 5. On 05/08/23 at 8:18 A.M., Registered Nurse (RN) #146 was observed administering medications to Resident #62. During preparation of the medications, RN #146 was observed removing the medications from their packaging and placing them in her bare hand prior to placing them in the medication cup. This was verified with RN #146 directly after leaving Resident #62's room. Review of the facility's policy, Administration and Documentation of Medications (revised October 2022), revealed standard precautions should be maintained while administering medication. Based on observation, interview, record review and policy review the facility failed to wear appropriate personal protective equipment (PPE) when the COVID-19 county transmission level was high, failed to maintain Resident #21's urine bag off the floor, failed to ensure ice scoops during ice pass on the North Hall (100 hall) were placed in a sanitary location when not in use, failed to ensure a nurse did not handle medications with her bare hands, and failed to ensure residents who were on enhanced barrier precautions had appropriate PPE for staff to wear when providing care. This affected four residents (Resident #21, #62, #66 and #224) observed for infection control procedures and had the potential to affect all 69 residents residing in the facility Findings included: 1. Observation on 05/07/23 at 8:30 A.M. upon entrance into the facility of signage at front entry revealing the COVID-19 county transmission level was high and staff were to wear masks and eye 365696 Page 22 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0880 protection. Level of Harm - Minimal harm or potential for actual harm Observation on 05/07/23 at 8:32 A.M. of Licensed Practical Nurse (LPN) #126 walking to the main entrance to turn off the door alarm. She was not wearing any mask or eye protection. When asked about not wearing any mask or eye protection she responded, I just took them off. Residents Affected - Many Observation on 05/07/23 at 8:35 A.M. of Speech Therapy #195 donning (putting on) a surgical mask at the nurses' station on the 100 hall. She was not wearing a mask prior. When asked about not wearing any mask she responded, I was hot and took my mask off. Observation on 05/07/at 8:39 A.M. of Dietary [NAME] #184 donning a surgical mask at the main entrance desk. He was not wearing any eye protection. When asked about not wearing any eye protection he responded, I usually do but not today. Interview on 05/07/23 at 8:48 A.M. with Registered Nurse #175 revealed the COVID-19 county transmission level had been high for weeks. Observation on 05/07/23 at 9:00 A.M. of Housekeeping #192 wearing a surgical mask but no eye protection. An interview at the time revealed he knew he should have eye protection on but did not. He revealed his eye protection was in his car. Observation on 05/07/23 at 9:01 A.M. of LPN #173 wearing a surgical mask but no eye protection. She was wearing her regular vision glasses. Interview at the time revealed she knew she should have eye protection on but did not. She reported there were no active cases of COVID-19 in the building. Review of the facility's COVID-19 county transmission level calendars for April 2023 and May 2023 revealed the COVID-19 county transmission levels had been red (high) since 04/13/23. Review of the facility policy titled, Infection Control Guidance, revised 10/22, revealed under the section use of personal protective equipment for staff, if COVID-19 infection is not suspected in a resident presenting for care (procedures and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all resident care encounters. Further review revealed at a minimum under general circumstances staff are required to wear a facemask when in halls and resident care areas. 2. Review of Resident #21's medical record revealed she was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy, acute and chronic diastolic (congestive) heart failure, generalized muscle weakness, paroxysmal atrial fibrillation, obstructive and reflux uropathy, non-pressure chronic ulcer of unspecified calf with unspecified severity, cellulitis of the right lower limb, stage 4 chronic kidney disease, depression, and anxiety. Review of Resident #21's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed she was mildly cognitively impaired and had an indwelling catheter. Review of Resident #21's current physician orders revealed Foley catheter size 16 French with 10 milliliter balloon to continues drain for diagnosis of obstructive uropathy, provide privacy bag. Foley catheter securement device to be monitored every shift and rotate sites weekly. Change Foley catheter as needed for obstruction, infection or system compromise. Catheter care every shift. 365696 Page 23 of 24 365696 05/10/2023 Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950

F 0880 Observation on 05/08/23 at 10:08 A.M. of Resident #21's covered urine bag lying on the floor. Level of Harm - Minimal harm or potential for actual harm Observation on 05/08/23 at 1:33 P.M. of Resident #21's covered urine bag lying on the floor by her wheelchair. Interview at the time with RN #175 verified the urine bag was on the floor and should not be due to infection control concerns. Residents Affected - Many Observation on 05/09/23 at 7:10 A.M. of Resident #21's covered urine bag lying on the floor by her bed. Interview at the time with RN #175 verified the urine bag was lying on the floor and should not be due to infection control concerns. 3. Observation on 04/09/23 at 11:42 A.M. of Resident Assistant #121 passing ice to residents on the North Hall (100 hall) revealed two ice scoops (one large and one small) lying on the surface where the ice cooler rested. There were noted white flecks of an unknown substance on the surface where the two scoops were lying. There was a mesh bag attached to the right side of the cart with nothing in the bag. An interview at the time with Resident Assistant #121 revealed she was not sure what to do with the scoops when she was not using them. She verified she had only been told not to leave the scoops in the cooler of ice. She verified the surface the cooler was sitting on could be dirty and she did not know what the white flecks were. 365696 Page 24 of 24