Health inspection·May 20, 2021

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/20/21 at 3:12 P.M. interview with the Director of Nursing (DON) revealed the facility was starting to complete audits for all new admissions and readmissions to determine their risks for drinking non-ingestible fluids and to make sure no periwash cleansers came from the hospital. She further revealed the facility hadn't reordered any PeriFresh since last year because it was not used that often. The DON revealed Resident #4 had no pica behaviors (a psychological disorder characterized by an appetite for substances that are largely non-nutritive), she never ingested toxic chemicals prior to that incident and following the incident staff pushed fluids for her. Review of the SDS revealed the substance labeled PeriFresh was not hazardous, would be irritating if ingested, if ingested drink large amounts of water and to contact the physician. On 05/19/21 at 3:52 P.M. interview with Director of Clinical Services (DCS) #90 revealed after the incident, they removed the periwash from the resident's room, notified the physician and poison control. The periwash wasn't toxic, but they didn't want the resident to continue to drink it. On 05/19/21 the facility began an audit to determine if other residents had periwash in their room and indicated they would meet collectively as an Interdisciplinary Team (IDT) to identify which residents should and shouldn't have it in their room. DCS #90 revealed the goal was to reduce the risk of this type of incident from occurring again, so the DON was also implementing formal education, as well and in-person education to staff. When asked about the immediate interventions for Resident #4 at the time of the incident (in February), DCS #90 revealed staff were utilizing the cleanser for her care, but were no longer leaving it in her room. However, no staff education had been completed at the time of the incident. On 05/20/21 at 12:30 P.M. interview with State Tested Nursing Assistant (STNA) #51 revealed Resident #4 would drink something/anything if it was put in front of her. On 5/20/21 at 12:14 P.M. interview with Licensed Practical Nurse (LPN) #22 revealed she was not aware of the incident with Resident #4 drinking periwash. LPN #22 further stated she knows not to leave any kind of liquid/non-drinkable items in Resident #4's room because she had worked as an STNA for several years prior to being a nurse, but she did not elaborate the specifics as to why this resident wasn't allowed liquids in her room. LPN #22 revealed she stopped using periwash for resident care on 05/19/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital records, review of a fall investigation, facility policy review and resident and staff interview the facility failed to provide timely and effective pain management for Resident #35 following a fall with injury. Residents Affected - Few Actual harm occurred on 09/15/20 at 2:15 P.M. when Resident #35, who exhibited moderate cognitive impairment and required extensive staff assistance for activities of daily living, sustained a fall with verbalization of pain, guarding to the right hip and an inability to bear weight following the incident. The facility failed to provide effective pain management/pain medication to the resident following the incident or notify the physician of the pain level. The resident was assessed to have pain rated a seven out of 10 on a scale from one to ten with ten being the worst pain and did not consume dinner on 09/15/20. The resident was subsequently diagnosed with a displaced fracture to the right hip which required surgical intervention. The resident was transported to the hospital on [DATE] at 9:15 P.M. (seven hours after the fall occurred). Hospital records revealed the resident's pulse was elevated at 101 beats per minute on 09/15/20 at 11:09 P.M. and upon physical examination, the resident was noted to be uncomfortable with a complaint of right hip pain with any attempted motion. The resident was medicated with narcotic pain medication in the hospital. This affected one resident (#35) of one resident reviewed for pain management. Findings include: Review of Resident #35's medical record revealed an original admission date on 04/13/20 and readmission on [DATE] with diagnoses including acute cystitis (urinary tract infection) without hematuria (blood in urine), cognitive communication deficit, lack of coordination, chronic kidney disease, spondylosis (a general term for age-related wear and tear of the spinal disks) in the lumbar region, prostate cancer, chronic atrial fibrillation, low back pain, bilateral osteoarthritis of hip, weakness, abnormalities of gait and mobility, presence of neurostimulator, essential tremor, ataxia (a lack of muscle control or coordination of voluntary movements such as walking), and a history of falling. Review of Resident #35's care plan, dated 07/24/20 and revised on 08/02/20 revealed the resident was at risk for pain. The plan revealed staff should administer medication as ordered and per the resident's preference and request. The resident should be assisted with repositioning as needed. Alternative pain relief measures should be attempted to include a back rub, relaxation, repositioning, exercise, or music prior to administering any PRN (as needed) medications. The physician should be consulted as needed related to the resident's pain. The resident should be observed for any signs or symptoms of pain, including any nonverbal signs of pain such as facial grimacing, restlessness, or grabbing an effected area. Therapy services as ordered by the physician. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/24/20 revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11 which reflected mild cognitive impairment. The assessment revealed the resident required extensive assistance from two staff to complete tasks including bed mobility and toileting and was totally dependent on two staff to complete transfers. The resident was not assessed for walking in his room due to the activity not occurring however, the resident was assessed to be unsteady and required staff assistance to stabilize when he moved on and off the toilet or completed a surface-to-surface transfer, for example transferred from his bed to a chair or wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few Review of physician's orders for Resident #35, for September 2020 revealed an order, initiated on 09/15/20 at 8:00 A.M. for Norco (a narcotic pain medication) 5-325 milligrams (mg) with instructions to administer the medication orally once daily for three days and then discontinue. The resident also had an order for Acetaminophen 650 mg with instructions to administer the medication orally three times daily for pain. Lastly, the resident had an order for Acetaminophen 650 mg with instructions to administer the medication orally every eight hours as needed for pain. The resident had an additional order to be monitored for any signs or symptoms of verbal or nonverbal pain every shift. Review of Resident #35's Medication Administration Record (MAR) from 09/01/20 to 09/30/20 revealed the resident received a dose of Norco 5-325 mg on 09/15/20 upon rising in the morning. The resident also received three doses of Acetaminophen 650 mg as routinely ordered on 09/15/20. There was no additional pain medication administered to the resident on 09/15/20. There was no documentation confirming whether the medication was effective in controlling the resident's pain. The resident was monitored for signs and symptoms of verbal and nonverbal pain in the morning on 09/15/20 and reported a pain level of five out of ten with ten being the worst pain. The resident was noted to be hospitalized during the night shift observation. Review of Resident #35's nursing progress notes revealed on 09/15/20 at 2:15 P.M. the resident had a fall while attempting to ambulate to the restroom without assistance. The resident was assessed by Licensed Practical Nurse (LPN) #22. The resident was noted to be guarding the area and stated he was having pain in his right hip area. The resident was not able to bear a lot of weight to his right leg. Neurological checks were initiated. Additionally, red areas were noted to the resident's left temple and right side of his head at his hairline. The resident's sister, the Director of Nursing (DON), and physician were notified of the fall and a new order was received for a STAT (immediate) x-ray of the resident's right hip/femur (thigh bone) area. There was no additional documentation in the nurse's notes regarding resident's pain level or status. Review of a written statement from LPN #22 dated 09/15/20, no time provided revealed the nurse responded to Resident #35's room at approximately 2:15 P.M. Upon entering, the resident was found sitting on the floor. The resident stated he was going to the bathroom. The note revealed the resident complained of right hip pain but after he was repositioned in his recliner, facial grimacing and guarding subsided and the resident stated the pain lessened. The resident received routine Norco medication (earlier that morning as scheduled) and routine Tylenol on this date. There was no additional documentation showing the resident was repositioned (or any other non-pharmaceutical interventions were utilized) more than one time when the fall occurred. Review of Resident #35's vital signs on 09/15/20 at 3:03 P.M. revealed the resident was assessed by staff using the Wong-Baker faces pain scale (a nonverbal pain scale). The scale ranges from zero to two with two being the highest indication of pain. The resident was assessed at a one for negative vocalization (occasional moan or groan or low level of speech with a negative quality), a two for facial expression (facial grimacing), a two for body language (rigid, fists clenched, knees pulled up, pulling or pushing away, striking out), and a two for consolability (unable to console, distract or reassure). These scores added together determined a pain level of seven out of ten with ten being the worst pain. There was no additional pain level/assessment documented on 09/15/20 after 3:03 P.M. There was no evidence the physician was contacted to discuss the resident's pain level. Review of Resident #35's meal intakes on 09/15/20 revealed the resident ate 75% to 100% at breakfast and lunch (documented at 1:38 P.M. and 1:39 P.M.). The resident's intake decreased to zero to 25% at dinner (documented at 6:37 P.M.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few Review of Resident #35's neurological checks on 09/15/20 from 2:20 P.M. to 8:05 P.M. revealed staff completed checks every 15 minutes for one hour, every 30 minutes for two hours, and every hour for three hours. The resident's blood pressure was 136/72 and his pulse was 86 at 2:20 P.M. At 4:05 P.M., the resident's blood pressure had increased to 144/72. At 5:05 P.M., the resident's blood pressure had increased to 146/66 and his pulse was 88. The resident's pain level was not assessed during any of the neurological checks. Review of Resident #35's fall scene investigation report, completed by LPN #8 and reviewed by the Assistant Director of Nursing (ADON), Social Services (SS) #77, Registered Nurse (RN) #6, the Administrator, and the Director of Nursing, dated 09/15/20 at 2:40 P.M., revealed on 09/15/20 at 2:15 P.M., the resident had an unwitnessed fall while ambulating alone to the bathroom in his room. The resident lost his balance, slipped, and appeared to become weak. The resident was alert and oriented. The investigation did not include any information related to addressing the resident's pain. The resident was not immediately taken to the hospital. The resident was educated on using his call light and waiting for staff to assist him. The Falls Team Meeting Notes at the end of the report stated a STAT (immediate) right lower extremity/hip x-ray was obtained and positive for a proximal femoral neck fracture. The resident was sent to the emergency room, admitted to the hospital, and was pending surgery. Record review revealed no Pain Assessment 3.0 was completed in the electronic charting system at the time of the incident. On 09/15/20 at 8:00 P.M. (nearly six hours after the resident's fall), the mobile x-ray provided arrived at the facility to complete the ordered hip and femur x-rays. Review of Resident #35's x-ray report, electronically signed on 09/15/20 at 8:32 P.M., revealed the findings included an oblique displaced fracture through the neck of the proximal right femur. There was limb retraction or cranial migration by approximately one centimeter (cm). On 09/15/20 at 8:50 P.M. (nearly seven hours after the resident's fall), a report was received from the mobile x-ray provider that confirmed the resident had a proximal right femur fracture and an order was received to send the resident to the emergency room. The Director of Nursing (DON), physician, and the resident's Power of Attorney (POA) were notified. On 09/15/20 at 9:15 P.M. Resident #35 was transferred to the hospital and remained hospitalized until 09/19/20. The resident returned to the facility on [DATE] at 1:50 P.M. with a 26 centimeter (cm) incision on his right hip with 17 staples. Review of the hospital information revealed the resident was administered Hydromorphone (used to treat moderate to severe pain) .5 mg per .5 milliliters (mL) intravenously one time. The resident had additional orders for Norco 5-325 mg every six hours as needed for pain, Acetaminophen 650 mg every four hours as needed for pain, and Morphine 2 mg intravenously every three hours as needed for pain during his hospital stay. Review of Resident #35's hospital records, dated 09/15/20 at 11:37 P.M., revealed the resident was seen in the emergency room for an evaluation of a right hip fracture. The x-ray showed an acute displaced fracture of the right femoral neck fracture with proximal displacement. The fracture was discussed with an orthopedic surgeon. The resident was admitted to the hospital with a plan for surgical intervention. The resident's pulse was elevated to 101 on 09/15/20 at 11:09 P.M. and upon physical examination, the resident was noted to be uncomfortable with a complaint of right hip pain with any attempted motion. The resident received pain medication including Hydromorphone 0.5 mg per 0.5 mL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm intravenously one time and had additional orders for Norco 5-325 mg every six hours as needed, Morphine two milligrams intravenously every three hours as needed, and Acetaminophen 650 mg every four hours as needed for pain. The resident underwent right hemiarthroplasty surgery on 09/17/20 and was discharged from the hospital on [DATE] at 10:38 A.M. Residents Affected - Few On 05/17/21 at 5:29 P.M. and 05/20/21 at 1:04 P.M. interviews with Resident #35 revealed the resident had a fall at the facility and he broke his leg. The resident stated he was scheduled to go home the day after the fall occurred had tried to walk to the bathroom by himself and fell. The resident stated following the fall he was in a lot of pain but thought the staff had given him a pain pill. He stated he continued to have a lot of pain until the time he was sent to the hospital. On 05/19/21 at 4:24 P.M. interview with LPN #22 revealed she responded to a call for a nurse to Resident #35's room on 09/15/20. She had not been assigned to the resident that day. The nurse stated she remembered the resident attempted to walk to the bathroom by himself and fell. The fall resulted in a hip fracture. The nurse stated the fall was not witnessed and a state tested nursing assistant (STNA) had found the resident on the floor and called for a nurse to assist. Since the fall was unwitnessed, the facility policy was to start neurological checks. The nurse confirmed the resident did complain of right hip pain and was not able to bear weight on his right leg. The nurse revealed the resident had received a scheduled Norco medication that morning (before the fall) as well as Tylenol in the afternoon and evening time. The nurse confirmed there was no documentation of whether the medication was effective or not with controlling the resident's pain. The nurse confirmed she did reposition the resident at the time of the fall and it did help reduce the resident's pain but she could not recall how often the resident had been repositioned (or if that occurred at all) before he went to the hospital. The nurse confirmed the physician was notified of the fall and the results of the resident's x-ray but had not been contacted to discuss the resident's pain. On 05/20/21 at 10:43 A.M. and 05/20/21 at 12:26 P.M. interview with the Assistant Director of Nursing (ADON) revealed she thought there was a four hour window for STAT orders to be completed and if it was going to take the provider longer than four hours, they should inform the facility. Later, the ADON revealed there was not a set turn around time for completing a STAT (immediate) x-ray in the contract with the mobile x-ray provider. The ADON revealed the resident agreed to have the x-rays completed at the facility instead of going to the hospital. However, the resident was not told that it could take several hours for the mobile x-rays to be completed because the wait time varied depending on how many drivers the provider had. The ADON confirmed the resident's pain level was assessed at a seven out of ten at 3:03 P.M. and there were no additional pain assessments recorded or documentation about the resident's pain level from 3:03 P.M. until the resident went to the hospital at 9:15 P.M. The ADON confirmed there was no documentation showing whether the medication administered to the resident was effective for controlling the resident's pain. The ADON confirmed there was not any documentation to determine the physician or Certified Nurse Practitioner (CNP) had been contacted to discuss the resident's pain level after the initial notification about the fall. The ADON confirmed a pain assessment was not included as part of the neurological checks that were completed on the resident. Review of the facility policy, titled Pain Management Program, revised on 06/12/17 revealed all residents would be reviewed upon admission, quarterly and prn (as needed) for acute (described as passing in nature), chronic, or no pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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** 2. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses of fracture of the left hip, morbid obesity and congestive heart failure. Residents Affected - Few The quarterly MDS 3.0 assessment, dated 02/04/21 revealed the resident had intact cognition and required extensive assistance from staff for bed mobility and transfers and was dependent on staff for dressing the lower body. Review of the current physicians' orders revealed Resident #21 was receiving the antibiotic, Dificid for clostridium difficle (C Diff) and had an order for contact isolation. On 05/18/21 at 9:15 A.M. observation of Resident's #21's room revealed a sign on the door to see the nurse before entering. There was a cart outside the door with personal protective equipment (PPE) that contained masks, gowns, and gloves. STNA #19 was observed to apply/don a paper gown and gloves, entered the resident's room and closed the door. Interview at the time of the observation revealed STNA #19 indicated she was going to get Resident #21 dressed for physical therapy. On 05/18/21 at 9:30 A.M. STNA #19 was observed coming out of Resident #21's room. The STNA was observed to continue to wear the paper isolation gown and was carrying a meal tray. STNA #19 walked around the corner of the hall with the meal tray and then came back to Resident #21's room and placed the meal tray on the cart outside the room that contained PPE. STNA #19 then went back into Resident #21's room and shut the door. Continued observation revealed the STNA #19 then exited the room, removed the paper gown she had been wearing and placed it on the door to the resident's room. The STNA picked up the meal tray and proceeded to walk down the hall carrying it. On 05/18/21 at 9:45 A.M. interview with Licensed Practical Nurse (LPN) #37 verified Resident #21 was on contact precautions for C Diff. LPN #37 revealed STNA #19 would need to wear a gown when in Resident #21's room only if she was providing incontinence care. LPN #37 revealed the gown should be removed prior to exiting the room and discarded. LPN #37 revealed she would dispose of the gown that was hanging on the resident's door. LPN #37 revealed the facility followed the Centers for Disease Control and Prevention (CDC) guidance related to the application and removal of gowns. On 05/18/21 at 2:30 P.M. interview with STNA #19 revealed she had gone in to Resident #21's room to assist the resident to get ready for therapy. She stated she helped him get dressed and put on his pants. She stated she was not thinking when she exited the room carrying the meal tray that she was still wearing the same gown and gloves that she had on in the room. On 05/20/21 at 2:36 P.M. the above findings were shared with the Administrator. Review of CDC guidelines for doffing/removal revealed to remove all PPE before exiting the patient room. As you remove the gown, peel off the gloves at the same time and place the gown and gloves into a waste container. Based on observation, record review, review of Centers for Disease Control and Prevention (CDC) guidance, review of facility policy and staff interview the facility failed to maintain adequate infection control practices during incontinence care for Resident #46 and during personal care for Resident #21 to prevent the spread of infection. This affected one resident (#46) of one resident observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 for incontinence care and one resident (#21) of three residents reviewed for isolation precautions. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1. Review of the medical record for Resident #46 revealed an admission date of 3/07/19 with diagnoses including Parkinson's disease, muscle weakness, benign prostatic hyperplasia (BPH), abnormal posture, and urine retention. Review of the plan of care, dated 03/14/19 revealed the resident was incontinent of bladder related to impaired mobility and diagnoses of BPH and urine retention with interventions to assist to the bathroom per resident request and toileting program, encourage fluids, assist with incontinence care, administer medications and obtain lab work as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment, with an assessment reference date of 04/07/21 revealed the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The assessment revealed the resident required extensive two staff assistance for bed mobility, transfers and toilet use and extensive one staff assistance for personal hygiene. The assessment revealed the resident was always incontinent or urine and frequently incontinent of bowel. On 05/19/21 at 10:40 A.M. State Tested Nursing Assistant (STNA) #31 and STNA #27 were observed providing incontinence care for Resident #46. During incontinence care, STNA #27 utilized six different wash cloths/towels, two to clean (with soap and water) the resident's peri-area and his buttocks, two to rinse his peri-area and buttocks, and two different towels to dry his peri area and buttocks. When she was finished with the wash cloths and towels, she sat the contaminated articles directly on the resident's bedside table without any type of barrier. After the care was completed, STNA #27 placed the resident's call light on the bedside table where the wet contaminated articles had been sitting in anticipation that she was completed with care and leaving the room. On 05/19/21 at 10:53 A.M. interview with STNA #27 confirmed she did not sanitize the resident's bedside table after placing the contaminated articles on it and also confirmed she sat the resident's call light on the wet contaminated bedside table. Review of the policy titled Perineal Care, dated 08/08/14 revealed the purpose of the policy was to prevent infections and odors and promote comfort for all residents who are unable to do self care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 8 of 8