Health inspection·April 20, 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 and staff interview the failed to ensure the advance directives and plan of care were accurate in the medical record for Resident #18. This affected one resident (#18) of 24 medical records reviewed. The facility census was 70. Findings include: Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and high blood pressure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set-up help only for personal hygiene. Review of the Physician Orders for 04/23 revealed Resident #18 had a code status of Do Not Resuscitate-Comfort Care (DNR-CC). Further documentation in the medical record revealed a Full Code form signed by the resident on 02/11/22. Review of the plan of care dated 02/23/22 revealed Resident #18 wished to be Full Code. On 04/19/23 at 12:23 P.M. an interview with Director of Clinical Services #99 verified the order was for DNR-CC, and provided the documentation, but the plan of care was for Full Code and signed form in the medical record was for Full Code. Page 1 of 24 365815 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with staff, and review of the facility policy the facility failed to provide resident privacy for Residents #54 and #271 when staff failed to knock before entering the room. This affected two residents (#54 and #271) of two reviewed for privacy. The facility census was 70. Residents Affected - Few Findings included: 1. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including displaced fracture of the right femur, atrial fibrillation, benign prostatic hyperplasia, diabetes, hyperlipidemia, Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often includes undermining and tunneling.), hypothyroidism, and hypertension. Observation on 02/20/23 at 12:16 P.M. Hospitality Aide #25 opened the door and walked into the room of Resident #54 with his lunch tray without knocking while the nurses were performing his wound care. She apologized and went right back out of the room. Licensed Practical Nurse (LPN) #48 verified Hospitality Aide #25 did not knock before entering Resident #54's room while he was exposed and receiving wound care. Review of the facility policy titled, Privacy, dated 12/14/92, revealed the purpose was to recognize the resident's rights to privacy and confidentiality. 2. Review of the medical record revealed Resident #271 was admitted to the facility on [DATE] with diagnoses including left ankle fusion surgery, neuromuscular dysfunction of the bladder, depression, fibromyalgia, atherosclerotic heart disease, diabetes, and hypertension. Observation on 04/19/23 at 8:23 A.M. revealed LPN #52 walked into the room of Resident #271 without knocking or announcing herself. She verified she did not knock prior to entering the resident's room. Review of the facility policy titled, Privacy, dated 12/14/92, revealed the purpose was to recognize the resident's rights to privacy and confidentiality. 365815 Page 2 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, record review, and facility policy review the facility failed to maintain a clean and sanitary environment. This affected two residents (#35 and #56) and had the potential to affect 17 additional residents (#4, #10, #16, #21, #22, #23, #25, #28, #37, #40, #49, #51, #52, #53, #55, #58, and #221) in the affected hallway. The facility census was 70. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 12/21/22. Diagnoses included scapula fracture, lack of coordination, chronic pulmonary disease, edema, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required no assistance with toileting. Observation on 04/17/23 at 8:20 P.M. revealed Resident #35 had a dirty toilet with diarrhea splattered on the seat and bowl. Resident #35 also had a pile of dirty linens on the floor that he reported were there from having an accident in his bed. The linens had a brownish yellow substance and had a strong odor that filled the room. Observation on 04/18/23 at 3:45 P.M. revealed the toilet remained dirty, and the pile of linens remained untouched in the corner of the room. Interview on 04/18/23 at 3:47 P.M. with Licensed Practical Nurse (LPN) #101 revealed she was not aware of the environmental concerns. Observation on 04/18/23 at 3:56 P.M. revealed State Tested Nurse Aide (STNA) #8 carrying dirty linens out of Resident #35's room. Interview with STNA #8 at the time of the observation verified the linens had bodily fluid on them and confirmed they should have been removed from the room should after they were soiled on 04/17/23. Interview on 04/19/23 at 8:45 A.M. Housekeeping Supervisor #27 revealed that resident rooms should be cleaned daily including soiled linens and resident bathrooms. She observed and confirmed Resident #35's toilet had splatter on the toilet seat and bowl and stated the staff would get it cleaned soon. Review of the undated facility policy titled Daily Room and Common Area Cleaning Routine revealed the resident toilets should be cleaned daily. 2. Review of the medical record for Resident #56 revealed an admission date of 11/18/22. Diagnoses included wedge compression fracture, muscle weakness, cognitive communication deficit, and heart failure. Review of the MDS assessment dated [DATE] revealed Resident #56 was cognitively intact and required no assistance with bed mobility or transferring. 365815 Page 3 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0584 Level of Harm - Minimal harm or potential for actual harm Interview and observation on 04/18/23 at 9:43 A.M. with Resident #56 revealed she had a fall on 02/10/23 near her room doorway, and there was a blood stain on the carpet as a result of her injury. The spot of blood remained on the carpet in the resident's room. Resident #56 revealed she had a second fall on 04/04/23 where she fell in the hallway, and there were blood stains in the hallway outside a neighboring room due to injuries from the fall. The blood was observed in the locations of residents fall in the hallway. Residents Affected - Some Observation on 04/18/23 at 3:47 P.M. revealed blood inside of Resident #56's doorway as well as blood outside in the hallway next to a neighboring room doorway. Interview on 04/19/23 at 8:45 A.M. with Housekeeping Supervisor #27 revealed that blood should have been cleaned up immediately and stated they use a peroxide solution that removes the blood stains. Housekeeping Supervisor #27 confirmed Resident #56's room and the hallway outside the room had visible blood stains. Interview on 04/20/23 at 3:10 P.M. with Director of Clinical Services (DCS) #99 revealed the facility had blood spill kits and they should be used to clean up all blood materials. Review of the facility policy titled Clean-Up Materials and Kits Available by Biohazard Container: Safety Procedures, dated 07/31/14, revealed the facility policy stated the facility should use a clean-up material kit that was a bactericidal according to the manufacturers specifications or materials to prepare a minimum ten percent sodium hypochlorite solution prepared immediately prior to use with a minimum of thirty minutes of contact time with waste. 365815 Page 4 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #33's was admitted to the facility on [DATE]. Diagnoses included adjustment disorder with mixed anxiety, depression, personality disorder, and post-traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33's cognition was intact. She required no assistance with bed mobility, transfers, dressing, toilet use, or personal hygiene. Review of the plan of care dated 04/11/23 revealed Resident #33 had PTSD and/or experienced a traumatic event(s)in the past. Potential for feelings of sadness, emptiness, anxiety, depression due to husbands diagnoses of cancer and unable to visit, diagnoses of depression, anxiety, paranoid personality disorder, and unspecified psychosis. Interview with Social Service #76 on 04/18/23 at 3:52 P.M. revealed the process was to review and update the PASSAR with new diagnoses when notified by nursing management. Social Service #76 verified the PASRR dated 03/04/17 was not updated with new diagnoses of psychosis and anxiety. Review of the Department of Medicaid informational slide presentation titled PASRR - What Nursing Facility Needs to Know revealed the section titled Resident Review 5160-3-15.2 (pages 36 - 40) and the section titled Significant Change in Condition (pages 47-50) Preadmission Screening and Resident Review are to be updated when there is a change in condition, including behavioral, psychiatric or mood related symptoms and diagnoses. Based on interview, medical record review, and review of the Department of Medicaid informational slide presentation titled PASRR - What Nursing Facility Needs to Know the facility failed to update Preadmission Screening and Resident Review (PASRR) with new mental illness diagnoses. This deficient practice affected three residents (#5, #43, and #33) out of three residents reviewed for PASRR requirements. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with admitting diagnoses of unspecified dementia and anxiety disorder. Review of Resident #5's medical record revealed medical diagnoses were updated on 05/22/19 with unspecified psychosis diagnoses and updated again on 01/01/22 with unspecified depression diagnoses. Review of Resident #5's initial PASRR dated 05/01/15 revealed in section D for medical diagnoses, anxiety was marked for mental illness. Review of Resident #5's medical record revealed no updated PASRR reflecting the updated mental illness medical diagnoses. Interview on 04/18/23 at 3:09 P.M. with Social Services #76 confirmed Resident #5's PASRR was not updated to reflect the new mental illness medical diagnoses received on 05/22/19 and 01/01/22. 365815 Page 5 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0644 Level of Harm - Minimal harm or potential for actual harm Review of the Department of Medicaid informational slide presentation titled PASRR - What Nursing Facility Needs to Know revealed the section titled Resident Review 5160-3-15.2 (pages 36 - 40) and the section titled Significant Change in Condition (pages 47-50) Preadmission Screening and Resident Review are to be updated when there is a change in condition, including behavioral, psychiatric or mood related symptoms and diagnoses. Residents Affected - Few 2. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with admitting diagnoses of unspecified dementia, unspecified psychosis, and unspecified mood disorder. Review of Resident #43's initial PASRR dated 03/11/21 revealed in section D there were no medical diagnoses marked, and the question for mental disorders was marked with no. Review of Resident #43 updated PASRR dated 04/21/22 revealed in section D there were no medical diagnoses marked to reflect Resident #43's medical diagnoses of unspecified psychosis and unspecified mood disorder. Interview on 04/18/23 at 3:09 P.M. with Social Services #76 confirmed Resident #43's PASRR dated 03/11/21 and updated 04/21/22 did not reflect Resident #43's medical diagnoses of unspecified psychosis and unspecified mood disorder. Review of the Department of Medicaid informational slide presentation titled PASRR - What Nursing Facility Needs to Know revealed the section titled Resident Review 5160-3-15.2 (pages 36 - 40) and the section titled Significant Change in Condition (pages 47-50) Preadmission Screening and Resident Review are to be updated when there is a change in condition, including behavioral, psychiatric or mood related symptoms and diagnoses. 365815 Page 6 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #18 had a care plan developed for the use of oxygen. This affected one resident (#18) of 23 residents reviewed for care plans. The facility census was 70. Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and high blood pressure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set-up help only for personal hygiene. Review of the physician's order dated 08/17/22 revealed an order for oxygen at two liters per minute via nasal cannula continuous. Review of the medical record revealed no documented evidence of a care plan for the use of oxygen. Interview on 04/20/23 at 3:45 P.M. with Director of Clinical Services (DCS) #99 verified there was no care plan developed for the use of oxygen for Resident #18. 365815 Page 7 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure neurological checks were completed for Resident #56 after a fall with a head injury. This affected one resident (#56) of five residents reviewed for falls. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record for Resident #56 revealed an admission date of 11/18/22. Diagnoses included wedge compression fracture, muscle weakness, cognitive communication deficit and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact and required no assistance with bed mobility or transferring. Review of the fall investigation dated 02/10/23 revealed another resident had wandered into Resident #56's room, and Resident #56 began escorting the other resident out of her room. Staff observed this and assisted the other resident in leaving. Resident #56 reached back to her wheelchair and fell. Resident #56 was observed to have a skin tear to her right elbow and a bump to the left/back side of her head. The investigation revealed blood was observed on the hook near the door and trailing down the wall. Review of the post fall assessment dated [DATE] revealed Resident #56 had a fall resulting in a skin tear to the right elbow and a bump to the left/back side of her head. The intervention put into place was for a stop sign to be placed on resident's door to alert wandering residents not to enter. The assessment revealed the resident had no history of previous falls and was a low risk at 9.0 for falls. The post fall assessment revealed no neurological checks were completed. Review of the medical record revealed no documented evidence of neurological checks for Resident #56's fall on 02/10/23. Review of the care plan dated 02/13/23 revealed Resident #56 was at risk for falls with interventions for staff to anticipate needs, have a stop sign placed in the doorway, place the call light within reach, and maintain areas free of clutter. Interview on 04/18/23 at 9:43 A.M. with Resident #56 revealed she had a fall in February of 2023 where she had a skin tear to her arm and a bump on her head. Interview on 04/20/23 at 9:36 A.M. with Director of Clinical Services (DCS) #99 confirmed residents with a head injury during a fall should have neurological checks for 72 hours according to the schedule. DCS #99 confirmed no neurological checks were completed for Resident #56 after the fall. The facility was unable to provide a policy related to neurological checks after a fall. 365815 Page 8 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to ensure fall interventions were implemented for two residents (#42 and #56) and failed to initiate a new fall prevention intervention for Resident #56 after a fall. This affected two residents (#42 and #56) of five residents reviewed for falls. The facility census was 70. Findings include: 1. Review of the medical record for the Resident #42 revealed an admission date of 02/16/23 with diagnoses including Parkinson's disease, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact and required extensive assistance of two staff members for transfers and bed mobility. Review of the baseline care plan dated 02/16/23 revealed Resident was at risk for falls due to having recent falls within the previous year with an intervention to keep the call light within reach. Review of the progress notes dated 03/06/23 revealed Resident #42 was found on the floor of her room after a fall while trying to go to the bathroom unassisted. Resident #42 had a change in range of motion, swelling, and pain and was sent to the hospital for further evaluation. The progress note dated 03/09/23 revealed Resident #42 returned to facility after diagnosis of left superior and inferior ramus fracture from the fall sustained on 03/06/23 with significant bruising on her bottom, back, abdomen, legs, and arms. Review of the plan of care dated 03/08/23 revealed Resident #42 was at risk for falls due to Parkinson's disease and history of falls with interventions to use the call light for assistance, and place visual reminders in the room to use the call light for assistance. Interview on 04/17/23 at 7:56 P.M. with Resident #42 revealed she had a fall about a month ago when trying to go to the bathroom unassisted. Resident #42 revealed she had not used the call light to request assistance. Observation on 04/19/23 at 9:00 A.M. revealed Resident #42 had no signage or visual cues to use the call light as per the care plan. Interview and observation on 04/19/23 at 9:25 A.M. with the Director and Nursing (DON) and Director of Clinical Services (DCS) #99 observed and confirmed the fall interventions were not in place. The DON and DCS #99 confirmed there were no signage of reminders to use the call light in place. 2. Review of the medical record for Resident #56 revealed an admission date of 11/18/22. Diagnoses included wedge compression fracture, muscle weakness, cognitive communication deficit, and heart failure. Review of the MDS assessment dated [DATE] revealed Resident #56 was cognitively intact and required no assistance with bed mobility or transfers. 365815 Page 9 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the fall investigation dated 02/10/23 revealed another resident had wandered into Resident #56's room. Resident #56 began escorting the resident out of her room. Staff observed this and assisted the other resident in leaving and when Resident #56 reached back to her wheelchair, she fell. Resident #56 was observed to have a skin tear on her right elbow and a bump to the back left side of her head. Review of the post fall assessment dated [DATE] revealed Resident #56 had a fall. The intervention put into place was for a stop sign to be placed on the resident's door to alert wandering residents not to enter. Review of the care plan dated 02/13/23 revealed Resident #56 was at risk of falling with interventions including having a stop sign placed in the doorway. Interview on 04/18/23 at 9:43 A.M. with Resident #56 revealed she had a fall in February of 2023 resulting in a skin tear to her arm and a bump on her head. Observation on 04/19/23 at 9:00 A.M. revealed Resident #56 had Velcro from a stop sign on the door, but there was no stop sign banner or signage as per the care plan. Interview and observation on 04/19/23 at 9:25 A.M. with the DON and DCS #99 observed and confirmed the fall prevention interventions were not in place. The DON and DCS #99 confirmed no stop sign was in place. Review of the facility policy titled Falls Policy and Procedure, dated 05/21/18, revealed the interdisciplinary team would develop interventions based upon the resident risk factors and individual needs and implement a fall care plan in the medical record. 3. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included wedge compression fracture, muscle weakness, cognitive communication deficit, and heart failure. Review of the MDS assessment dated [DATE] revealed Resident #56 was cognitively intact and required no assistance with bed mobility or transferring. Review of the care plan dated 02/13/23 revealed Resident #56 was at risk of falls with interventions for staff to anticipate needs, have a stop sign placed in the doorway, place the call light within reach, and maintain areas free of clutter. Review of fall investigation dated 04/04/23 revealed staff heard a noise and found Resident #56 lying on the ground in the hallway outside a neighboring room with a laceration noted to the left inner knee and two skin tears noted to the right knee. Resident #56 was transferred to the emergency room and received stitches and returned to the facility. Review of the medical record revealed no new fall prevention intervention was initiated after Resident #56's fall on 04/04/23. Interview on 04/18/23 at 9:43 A.M. with Resident #56 revealed she had a fall in April 2023 in the hallway outside of her room. 365815 Page 10 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/19/23 at 10:05 A.M. with DCS #99 confirmed no new fall intervention was initiated after Resident #56 fell in the hallway on 04/04/23. Review of the facility policy titled Falls Policy and Procedure, dated 05/21/18, revealed the interdisciplinary team would develop interventions based upon the resident risk factors and individual needs and implement a fall care plan in the medical record. The policy also revealed residents with one or more falls would have applicable interventions implemented and documented on the plan of care in the medical record. 365815 Page 11 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, review of the continuous positive airway pressure (CPAP) cleaning instructions, and facility policy review the facility failed to ensure respiratory equipment was dated and maintained in a clean and sanitary manner for Residents #18, #29, and #36. This affected three residents (#18, #29 and #36) of 13 residents who received oxygen/respiratory therapy. The facility census was 70. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set-up help only for personal hygiene. Observation on 04/18/23 at 9:05 A.M. revealed Resident #18's oxygen tubing was dated 04/07/23. The nebulizer tubing was not dated and was uncovered. On 04/18/23 at 10:48 A.M. interview with Corporate MDS Nurse #101 verified the above finding. Review of the April 2023 treatment administration record (TAR) for Resident #18 revealed the oxygen tubing was signed off as being changed on 04/14/23. 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia, atrial fibrillation, osteoporosis, Stage III chronic kidney disease, peripheral vascular disease (PVD), depression, anxiety, pacemaker, and adult failure to thrive. Review of the annual MDS assessment dated [DATE] revealed Resident #29's cognition was moderately impaired. She requires extensive assistance from one staff member for transfers, bed mobility, dressing, and personal hygiene, and extensive assistance of two or more staff members for toilet use. Resident #29 was receiving hospice services. Observation on 04/18/23 at 8:58 A.M. revealed Resident #29's oxygen tubing dated 04/07/23. On 04/18/23 at 10:51 A.M. an interview with Licensed Practical Nurse (LPN) #41 verified the above findings. Review of the April 2023 TAR for Resident #29 revealed the oxygen tubing was signed off as being changed on 04/14/23. Review of the policy and procedure titled Oxygen Therapy, revised 08/07/14, revealed humidifiers and oxygen tubing must be dated/initialed and changed weekly per the oxygen company. e 3. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including COPD and sleep apnea. 365815 Page 12 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/18/23 at 11:15 A.M. revealed Resident #36 had a nebulizer machine sitting on the nightstand with a handheld mouthpiece lying on top of the machine without a barrier underneath the mouthpiece. The undated tubing was observed attached from the nebulizer machine to the handheld mouthpiece. Sitting on the nightstand beside the nebulizer machine was a CPAP machine with tubing and air hose attached to a face mask that was lying on the floor between the bed and the nightstand without a barrier under the face mask. Review of the physician's orders revealed Resident #36 was ordered Albuterol Sulfate Nebulizer Solution 2.5 milligrams (mg) per three milliliters (ml) one vial four times a day for shortness of breath and a CPAP machine at setting #9 at bedtime for sleep apnea. Review of respiratory care plan revised 03/08/23 revealed medications to be administered per physician order and oxygen to be used for shortness of breath. Interview on 04/18/23 at 11:20 A.M. LPN #52 confirmed the nebulizer machine on the nightstand with undated tubing attached to the handheld mouthpiece lying on the nebulizer machine without a barrier underneath and the CPAP machine located beside the nebulizer with the tubing and air hose attached to a face mask lying on the floor between the bed and the nightstand without a barrier underneath the face mask. Review of the policy titled Specific Medication Administration Procedures, dated 07/01/21, stated when treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece, and medication cup. Rinse and disinfect the nebulizer equipment per manufacturer's recommendations. When the equipment is completely dry, store it in a plastic bag with the resident's name and date on it. Change equipment and tubing every seven days. Review of the CPAP cleaning instructions by Respiratory Care Partners (RCP) revealed tubing, air hose, and face mask are to be cleaned, allowed to air dry, and then stored in a plastic bag with resident's name. 365815 Page 13 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy the facility failed to ensure laboratory tests ordered by the physician were completed. This affected one resident (#19) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), diabetes, depression, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19's cognition is moderately impaired. She required extensive assistance from one staff member for bed mobility, dressing, toilet use, and personal hygiene and extensive assistance with two or more staff for transfers. Review of the physician's orders revealed an order for a complete blood count (CBC) every month. Review of the completed laboratory results revealed the CBC was not completed for July 2022. On 04/20/23 9:29 A.M. interview with Director of Clinical Services (DCS) #99 verified the laboratory test scheduled for July 2022 was not completed as ordered. Review of the policy and procedure titled Laboratory and Diagnostic Services, dated 11/16/16, revealed all residents will receive diagnostic services and follow up care per clinical practitioner orders in accordance with federal and state requirements: The facility will obtain or provide diagnostic services per order of physicians, Nurse Practitioners or Physician Assistant in accordance with state law including scope of practice laws. 365815 Page 14 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure timely dental services for Resident #18. This affected one resident (#18) of two residents reviewed for dental services. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set up help only for personal hygiene. Observation on 04/18/23 10:15 A.M. revealed Resident #18 had lower teeth missing teeth. Resident #18 stated, I need them to be taken care of. Review of the plan of care dated 02/23/22 revealed Resident #18 was at risk for oral complications because she had upper dentures and her own lower teeth. Review of the Dental Notes dated 09/09/22 revealed in-house dental service stated tooth #27 was fractured off but was asymptomatic. Teeth #27 and #21 were only root tips and should be removed as needed. There was no documented evidence the facility had arranged services from an outside dentist to follow up on the 09/09/22 in-house dental visit. The facility does have a dentist that comes to the facility and provides routine exams, cleaning, and denture fitting. On 04/20/23 at 10:30 A.M. an interview of Social Service (SS) #76 revealed that nursing would be the one to schedule the appointment to have the outside dental services completed, and she would check to see if they had scheduled anything. On 04/20/23 at 11:31 A.M. an interview with the Administrator revealed they had not made an appointment for outside dental services because it said as needed. The Administrator stated she called Resident #18's son and asked who her dentist was, and he did not know. She stated she then called a dentist that accepted Medicaid, and Resident #18 has an appointment scheduled for 04/28/23. 365815 Page 15 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide Residents #14 and #21 all items on the specified diet menu. This affected two residents (#14 and #21) of two residents reviewed for pureed diets. The facility census was 70. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 09/17/20 with diagnoses including Alzheimer's disease and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired and required set up assistance for eating. Review of the plan of care dated 03/29/23 revealed Resident #21 was at risk for altered nutrition related to Alzheimer's disease. Interventions included providing diet as ordered, encouraging intake, and providing supplements as ordered. Review of the physician's orders dated 02/07/23 revealed orders for a regular diet with pureed texture and thin liquids. 2. Review of the medical record for the Resident #14 revealed an admission date of 04/16/20 with diagnoses including dementia without behaviors, kidney disease, and dysphasia. Review of the MDS assessment dated [DATE] revealed Resident #14 was cognitively impaired and required limited assistance of one staff member for eating. Review of the plan of care dated 02/14/23 revealed Resident #14 was at risk for altered nutrition related to dementia. Interventions included providing diet as ordered, encouraging intake, and providing supplements as ordered. Review of the physician's orders dated 02/14/23 revealed orders for a regular diet with pureed texture and thin liquids. Review of the pureed menu spreadsheets revealed the dinner menu on 04/20/23 included pureed crab cakes, pureed rice, pureed vegetable blend, pureed bread, and pureed chilled fruit cocktail. Observation on 04/19/23 from 4:00 P.M. to 4:20 P.M. revealed kitchen staff had pureed rice, pureed vegetable medley, and pureed crab cakes for the dinner meal. Observation on 04/19/23 at 4:25 P.M. revealed Kitchen Staff #51 placed a scoop of pureed rice, pureed crab cake, and pureed vegetables on a plate. The pureed food was taken to the dining room and served to Residents #14 and #21 who already had a cup of food in front of them. Interview on 04/19/23 at 4:30 P.M. with Dietary Manager #16 revealed the cup of food was pureed fruit cocktail and was made earlier to be passed out by staff in the dining room. 365815 Page 16 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/19/23 from 4:25 P.M. to 4:40 P.M. revealed Residents #14 and #21 were not provided with pureed bread. Interview on 04/19/23 at 4:40 P.M. with Dietary Manager #16 revealed the two residents on pureed diets did not ask for pureed bread so none was made for them. Dietary Manager reported the facility had a bread mix that was used for pureed breads. Interview on 04/20/23 at 2:21 P.M. with State Tested Nurse Aides (STNAs) #27 and #44 revealed neither Resident #14 nor Resident #21 have the capacity to understand their meal choices and decline certain items. The STNA's revealed both residents typically get the main special except if they have an allergy. The STNAs revealed neither resident had many foods they disliked and confirmed neither Resident #14 nor Resident #21 disliked bread and thought they were not given bread as the facility was unable to make pureed bread. The facility was unable to provide a policy related to providing foods according to the menus. 365815 Page 17 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observations, interviews, record review, review of recipe instructions, and review of the facility policy the facility failed to make pureed food according to the recipe to ensure high nutritional value. This affected two residents (#14 and #21) of two residents who were on a pureed diet. The facility census was 70. Finding include 1. Review of the medical record for Resident #21 revealed an admission date of 09/17/20 with diagnoses including Alzheimer's disease and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired and required set up assistance for eating. Review of the plan of care dated 03/29/23 revealed Resident #21 was at risk for altered nutrition related to Alzheimer's disease. Interventions included providing diet as ordered, encouraging intake, and providing supplements as ordered. Review of the physician's orders dated 02/07/23 revealed orders for a regular diet with pureed texture and thin liquids. 2. Review of the medical record for the Resident #14 revealed an admission date of 04/16/20 with diagnoses including dementia without behaviors, kidney disease, and dysphasia. Review of the MDS assessment dated [DATE] revealed Resident #14 was cognitively impaired and required limited assistance of one staff member for eating. Review of the plan of care dated 02/14/23 revealed Resident #14 was at risk for altered nutrition related to dementia. Interventions included providing diet as ordered, encouraging intake, and providing supplements as ordered. Review of the physician's orders dated 02/14/23 revealed orders for a regular diet with pureed texture and thin liquids. Review of the recipe instructions for the pureed vegetable blend dated 01/11/23 stated to blend prepared product until desired consistency is reached adding liquid as needed. The recipe also stated thickener may be needed to achieve the desired consistency. Observation and interview on 04/19/23 from 3:30 to 4:00 P.M. with Kitchen Staff #51 preparing a vegetable blend pureed for three residents (one was made for an assisted living resident). Kitchen Staff #51 scooped three, one-half cup scoops of vegetables into the Robo Coupe blender and added one cup of warm water and an unmeasured amount of thickener powder. Kitchen Staff #15 revealed she added about/under one tablespoon of thickener. Observation appeared to be about one to two tablespoons of thickener. Kitchen Staff #15 looked at the recipe but did not properly follow instructions. Observation on 04/19/23 at 4:56 P.M. revealed Resident #14 stated the food doesn't taste good. 365815 Page 18 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff were attempting to help feed Resident #14, and she declined to eat the pureed food. Staff informed her that is vegetables and resident stated, it doesn't taste like it. Staff stated the two residents (#14 and #21) who are on pureed diets often report not liking what was served. Interview on 04/19/23 at 5:46 P.M. with Kitchen Staff #51 confirmed adding liquid and thickener can take away from the nutrients and the ingredients should be blended to see if an additive of liquid or thickener would be needed. Review of facility policy titled Puree food production procedure, dated 12/11/14, revealed the facility should ensure proper production of pureed food items regarding texture, consistency, sanitation, and nutritional integrity. The policy also revealed that pureed food should have a minimal amount of thickener and liquid added to preserve nutritional integrity. 365815 Page 19 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. Observation on 04/18/23 at 7:56 A.M. revealed State Tested Nurse Aide (STNA) #66 and STNA #69 passing room trays on C hall to Residents #7, #34, #50, #59, and #120. STNA #66 and STNA #69 were not washing their hands or using hand sanitizer in between resident rooms. Interview on 04/18/23 at 8:12 A.M. with STNA #66 and STNA #69 verified they did not wash their hands or use hand sanitizer in between resident rooms. Review of the facility policy and procedure Hand Washing, revised 12/07/22, revealed hand washing is the simplest, easiest, most economical way to prevent the spread of infection. Employees shall at minimum wash their hands: 1. Before, during, and after handling food or beverages. 2. After patient contact. Based on observation, staff interviews, and facility policy review the facility failed to ensure safe and proper storge of food items in the dry storage, refrigerator, and freezer. This had the potential to affect all residents, as all residents receive food from the kitchen. The facility also failed to ensure proper handwashing by staff while passing meal trays to resident rooms. This affected five residents (#7, #34, #50, #59, and #120) observed to be affected during the tray passing observation. The facility census was 70. Findings include: 1. Observation and interview on 04/17/23 at 6:50 P.M. with Kitchen Staff #71 confirmed the following findings of food storage: Refrigerator Cups of milk were covered and undated. A water pitcher was left uncovered. Freezer An opened bag of French fries was found updated. A second bag of French fries was left open to air and undated. An opened bag of tater tots was found undated. Observation and interview on 04/17/23 at 9:10 P.M. with Dietary Manager #16 confirmed the following findings of food storage: Refrigerator A pie did not have a label and was undated. 365815 Page 20 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0812 A sheet tray full of fruit cups (melon) were left undated. Level of Harm - Minimal harm or potential for actual harm A sheet tray full of Jell-O cups were left undated. A pitcher of what appeared to be iced tea was left unlabeled and undated. Residents Affected - Many Freezer Broccoli was found to be undated. Corn was found to be undated. Peas were found to be undated. Waffles were found to be open to air and left undated. Dry storage Brownie mix was found to be open to air and undated. Review of the facility policy titled Food Storage Dry Goods, dated 06/20/17, revealed all items will be sealed properly and will be dated upon delivery and dated with the opening date. Review of the facility policy titled Food Storage Cold, dated 06/20/17, revealed dietary staff will ensure that all refrigerated food items will be stored properly, labeled, and dated and arranged in a manner that will prevent cross contamination. 365815 Page 21 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

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. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including displaced fracture of the right femur, atrial fibrillation, benign prostatic hyperplasia, diabetes, hyperlipidemia, Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling), hypothyroidism, and hypertension. Residents Affected - Some Review of the five-day MDS assessment dated [DATE] revealed Resident #54 had intact cognition and a Stage IV pressure ulcer present upon admission. Review of the April 2023 physician's orders revealed Resident #54 had an order dated 04/20/23 for a sacrum wound negative pressure wound vacuum therapy continuously at 125 millimeters of mercury (mmHg) with white foam and black foam. It was to be changed three times weekly on Tuesday, Thursday, and Sunday. Observation on 04/20/23 at 12:00 P.M. revealed Licensed Practical Nurse (LPN) # 20 and LPN #48 provided wound care to the sacrum of Resident #54. Continued observation revealed both nurses washed their hands and donned gloves prior to starting the procedure. LPN #20 placed paper towels down on the bedside table leaving about two inches of the table exposed. LPN #20 stated she had forgotten gauze and normal saline (NS) so LPN #48 left the room to go retrieve the items. When LPN #48 returned into the room, she placed the exposed gauze directly on the bedside table without the barrier. LPN #20 picked up the gauze and placed them on the barrier. LPN #20 proceeded to remove the wound vacuum dressing with her gloved hands and threw the soiled dressing in the trash can. She then picked up the gauze and NS ampule, cleansed the outer wound and then the wound bed without changing her soiled gloves or washing her hands. An interview at 12:33 P.M. LPN #20 verified she had not changed her gloves after removing the soiled dressing prior to cleaning the wound but was told that was how she was supposed to do it from management. Review of the [NAME] Skills Checklist for Fundamentals of Nursing, The Art and Science of Nursing care revealed after removing the soiled dressing to remove gloves and dispose of them prior to cleaning the wound. Questions for #3 and #4 in red Based on observations, staff interviews, resident interviews, record reviews, review of the [NAME] Skills Checklist for Fundamentals of Nursing, The Art and Science of Nursing, and facility policy review the facility failed to ensure blood was cleaned up in a timely manner for Resident #56 after a fall in the hallway. This affected one resident (#56) and had the potential to affect 17 additional residents (#4, #10, #16, #21, #22, #23, #25, #28, #37, #40, #49, #51, #52, #53, #55, #58, and #221) in the affected hallway. The facility also failed to ensure proper hand hygiene was performed during medication administration for two residents (#271 and #273), during wound care for one resident (#54), and during meal tray pass for 5 residents (#7, #34, #50, #59, and #120). This had the potential to affect all residents residing in the facility. The facility census was 70. Findings include: 1. Review of the medical record for Resident #56 revealed an admission date of 11/18/22. Diagnoses 365815 Page 22 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0880 included wedge compression fracture, muscle weakness, cognitive communication deficit, and heart failure. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact and required no assistance with bed mobility or transferring. Residents Affected - Some Interview and observation on 04/18/23 at 9:43 A.M. with Resident #56 revealed she had a fall on 02/10/23 near her room doorway, and there was a blood stain on the carpet as a result of her injury. The spot of blood remained on the carpet in the resident's room. Resident #56 revealed she had a second fall on 04/04/23 where she fell in the hallway, and there were blood stains in the hallway outside a neighboring room due to injuries from the fall. The blood was observed in the locations of residents fall in the hallway. Observation on 04/18/23 at 3:47 P.M. revealed blood inside of Resident #56's doorway as well as blood outside in the hallway next to a neighboring room doorway. Interview on 04/19/23 at 8:45 A.M. with Housekeeping Supervisor #27 revealed that blood should have been cleaned up immediately and stated they use a peroxide solution that removes the blood stains. Housekeeping Supervisor #27 confirmed Resident #56's room and the hallway outside the room had visible blood stains. Interview on 04/20/23 at 3:10 P.M. with Director of Clinical Services (DCS) #99 revealed the facility had blood spill kits and they should be used to clean up all blood materials. Review of the facility policy titled Clean-Up Materials and Kits Available by Biohazard Container: Safety Procedures, dated 07/31/14, revealed the facility policy stated the facility should use a clean-up material kit that was a bactericidal according to the manufacturers specifications or materials to prepare a minimum ten percent sodium hypochlorite solution prepared immediately prior to use with a minimum of thirty minutes of contact time with waste. 3. Record review revealed Resident #273 had an order dated 04/18/23 for Vancomycin 1.25 grams per 250 milliliters (ml) twice daily via intravenous (IV) administration for septic arthritis. Resident #273 During medication administration observation on 04/19/23 at 8:11 A.M. Registered Nurse (RN) #70 placed packaged supplies on the unmade bed, washed hands, and donned gloves. RN #70 prepared the medication for administration and cleansed the medication port to the peripherally inserted central catheter (PICC) line located in Resident #273's right upper arm. RN #70 administered the IV antibiotic to Resident #273 using a medication infusion pump programmed for 90 minutes of infusion. RN #70 removed the gloves and left the room without performing hand washing, touched the medication cart, signed off the medication in the medication administration record, and proceeded down the hall with the medication cart. Interview on 04/19/23 at 8:14 A.M. with RN #70 confirmed the absence of hand washing following the removal of gloves at the completion of the medication administration. Review of the facility policy titled Hand Washing, revised 12/07/22, revealed hands are to be washed following removal of gloves and before contact with another resident. 365815 Page 23 of 24 365815 04/20/2023 Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Record review revealed Resident #271 had an order 04/13/23 for blood sugar checks before meals and at bedtime for diabetes mellitus. During medication administration observation on 04/19/23 at 11:30 A.M. LPN #52 gathered the glucometer, glucometer strip, alcohol wipe, and lancet from the medication cart. LPN #52 entered Resident #271 room, placed supplies on a paper towel as the barrier, washed hands, and donned gloves. LPN #52 cleansed Resident #271 right middle finger with the alcohol wipe, pricked the skin with the lancet, and collected the blood sample using the glucometer strip inserted in the glucometer. LPN #52 removed gloves and disposed of them in the trash can, gathered the used supplies and left the room without washing hands. LPN #271 placed the used glucometer on the medication cart without a barrier underneath. LPN #52 donned gloves removed a bleach wipe from the medication cart and cleansed the glucometer. Following glucometer cleaning, LPN #52 placed the glucometer in a cup to dry, removed gloves and began to document results of blood sugar check without washing or sanitizing hands prior to touching the computer keyboard. Interview on 04/19/23 at 11:40 A.M. with LPN #52 confirmed the absence of hand washing following removal of gloves and prior to using the computer keyboard. Review of the facility policy titled Hand Washing, revised 12/07/22, revealed hands are to be washed following removal of gloves and before contact with another resident. 5. Observation on 04/18/23 at 7:56 A.M. revealed State Tested Nurse Aide (STNA) #66 and STNA #69 passing room trays on C hall to Residents #7, #34, #50, #59, and #120. STNA #66 and STNA #69 were not washing their hands or using hand sanitizer in between resident rooms. Interview on 04/18/23 at 8:12 A.M. with STNA #66 and STNA #69 verified they did not wash their hands or use hand sanitizer in between resident rooms. Review of the facility policy and procedure Hand Washing, revised 12/07/22, revealed hand washing is the simplest, easiest, most economical way to prevent the spread of infection. Employees shall at minimum wash their hands: 1. Before, during, and after handling food or beverages. 2. After patient contact. 365815 Page 24 of 24