Health inspection·June 23, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 3. Review of Resident #10's medical record revealed diagnoses including urinary and fecal incontinence, multiple sclerosis, diabetes mellitus, asthma, and major depressive disorder. Residents Affected - Few Review of the annual MDS 3.0 assessment, dated 02/04/22 revealed Resident #10 indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. A quarterly MDS 3.0 assessment, dated 06/03/22 indicated Resident #10 was able to make herself understood and was able to understand others. Resident #10 was assessed as cognitively intact. The assessment revealed Resident #10 was totally dependent on staff for transfers and required physical help in part of bathing activity. Review of Resident #10's shower records revealed for April and May 2022 the resident was scheduled to receive a shower three times per week. Review of the bathing documents for April 2022 revealed only two showers were provided the weeks beginning 04/03/22 and 04/10/22 and one shower was provided the week beginning 04/24/22. Review of the May 2022 bathing documents revealed only one shower was provided the week beginning 05/08/22, two showers were provided the week beginning 05/15/22 and no showers were recorded between 05/20/22 and 05/31/22. Review of June 2022 bathing records revealed two showers were scheduled per week, on Monday and Thursday. A notation on 06/08/22 revealed a shower was not given because staff were pulled to the floor. On 06/14/22 at 9:20 A.M. interview with Resident #10 revealed she was supposed to get showers three times a week but sometimes only received one shower. The resident indicated she was also unable to get a bed bath. On 06/21/22 at 10:45 A.M. the Director of Nursing (DON) was interviewed regarding documentation revealing showers were not provided according to the resident's preference. The DON indicated she believed she might be able to find additional documentation to reflect showers were actually provided. On 06/21/22 at 3:21 P.M. the Administrator revealed the facility was unable to find any additional information regarding showers for Resident #10. The resident had not received showers per her preference and the Administrator verified Resident #10 was oriented. This deficiency substantiates Complaint Number OH00131579. Page 1 of 23 365822 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0561 Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure residents were assisted with showers as per their preference. This affected three residents (#10, #17, #46) of 18 residents interviewed regarding choices and showers. Findings include: Residents Affected - Few 1. Review of the medical record for Resident #46 revealed an admission date of 08/10/21 with diagnoses including osteomyelitis, incomplete paraplegia, major depressive disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22 revealed Resident #46 was cognitively intact and required two person assistance for bathing. Review of Resident #46's shower records from April 2022 through 06/15/22 revealed showers were scheduled every Monday, Wednesday and Friday. The facility provided documentation of showers completed on 04/05/22, 04/11/22, 04/12/22, 04/18/22, 04/20/22, 04/22/22, 04/27/22, 05/02/22, 05/04/22, 05/13/22, 05/18/22, 05/20/22, 05/30/22, 06/05/22, 06/10/22 and 06/15/22. This reflected instances of Resident #46 not receiving showers on the scheduled days. On 06/14/22 at 11:45 A.M., interview with Resident #46 revealed a concern showers were not provided routinely. The resident voiced he was supposed to receive a shower on 06/13/22 but stated he did not get a shower because the shower aide was too busy to give him a shower. On 06/21/22 at 2:00 P.M. interview with State Tested Nurse Aide (STNA) #460 verified showers were not always completed as scheduled because she was the only designated shower aide for her assigned area and was often pulled to work as an aide the floor. She said being the only shower aide for the unit made it difficult to complete all showers as scheduled. She also stated showers did not get completed by the STNAs on the floor when she was not at the facility. 2. Review of the medical record for Resident #17 revealed an admission date of 06/03/20 with diagnoses including congestive heart failure, type two diabetes mellitus, muscle weakness, and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment, dated 04/0822 revealed Resident #17 was cognitively intact and required one person assistance for bathing. Review of Resident #17's shower records from April 2022 through 06/15/22 revealed showers were scheduled for every Monday and Wednesday. The facility provided documentation of bathing being provided on 04/04/22, 04/06/22, 04/11/22, 04/20/22, 04/25/22, 04/27/22, 05/03/22, 05/05/22, 05/09/22, 05/11/22, 05/18/22, 05/23/22, 06/01/22, 06/06/22, 06/08/22, 06/13/22 and 06/15/22. This reflected large gaps up to nine days between documented showers or bathing activities for the resident. On 06/14/22 at 11:20 A.M. interview with Resident #17 revealed a concern that showers were not provided routinely. The resident was unable to recall the last time she had actually received a shower. 365822 Page 2 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0561 Level of Harm - Minimal harm or potential for actual harm On 06/21/22 at 2:00 P.M. interview with State Tested Nurse Aide (STNA) #460 verified showers were not always completed as scheduled because she was the only designated shower aide for her assigned area and was often pulled to work as an aide on the floor. She said being the only shower aide for the unit made it difficult to complete all showers as scheduled. She also stated showers did not get completed by the STNAs on the floor when she was not at the facility. Residents Affected - Few 365822 Page 3 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review and interview the facility failed to ensure residents were invited to participate in meetings discussing and developing their plan of care. This affected three residents (#10, #41 and #45) of 18 residents who were interviewed regarding participation in development of their plan of care. Findings include: 1. Review of Resident #10's medical record revealed diagnoses including multiple sclerosis, muscle spasms, diabetes mellitus, asthma, depression, chronic pain, and slow transit constipation. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/03/22 revealed Resident #10 was able to make herself understood, was able to understand others and was cognitively intact. Review of progress notes, dated 08/13/21 at 9:36 A.M., 12/17/21 at 9:51 A.M., 02/11/22 at 9:47 A.M. and 06/10/22 at 10:18 A.M. revealed plan of care meetings were held on these dates. Family were invited and did not attend. There was no documentation of resident attendance or input for the meetings. On 06/14/22 at 9:29 A.M. interview with Resident #10 revealed she was not invited to participate in setting goals and planning her care. On 06/14/22 at 3:00 P.M. interview with Social Service Designee (SSD) #480 revealed when care conferences were held, families were notified by mail. SSD #480 revealed she was unaware of residents being invited to participate in the meetings. On 06/15/22 at 1:30 P.M. interview with the Director of Nursing (DON) revealed care conferences were geared toward family so they could receive updates from all disciplines. If family wanted a resident to attend, the resident could be included. Families were notified of care plan meetings by mail. Residents did not receive notification as far as she was aware. On 06/21/22 at 3:21 P.M. interview with the Administrator revealed the facility used to go around and ask residents if there were any concerns prior to the care conferences held before the COVID pandemic. The Administrator verified residents should be given an opportunity to participate in the care planning process. 2. Review of Resident #41's medical record revealed diagnoses including end stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, depression, chronic pain, and diabetes mellitus. A quarterly MDS 3.0 assessment, dated 05/06/22 revealed Resident #41 was usually able to make herself understood and was usually able to understand others. Resident #41 was assessed as moderately cognitively impaired. Review of a social service note, dated 08/23/21 at 2:41 P.M. revealed a care conference was held with Resident #41's guardian. A social service note, dated 02/11/22 at 9:45 A.M. indicated a plan of care meeting was held. The guardian was invited and did not attend. An MDS note, dated 05/13/22 at 365822 Page 4 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0657 Level of Harm - Minimal harm or potential for actual harm 9:42 A.M. revealed a plan of care meeting was held. Family was invited and did not attend. None of the notes revealed participation of Resident #41 in the discussions regarding her plan of care. On 06/13/22 at 4:14 P.M. interview with Resident #41 revealed she was not invited to participate in setting goals and planning her care. Residents Affected - Few On 06/14/22 at 3:00 P.M. interview with Social Service Designee (SSD) #480 revealed when care conferences were held, families were notified by mail. SSD #480 revealed she was unaware of residents being invited to participate in the meetings. On 06/15/22 at 1:30 P.M. interview with the Director of Nursing (DON) revealed care conferences were geared toward family so they could receive updates from all disciplines. If family wanted a resident to attend, the resident could be included. Families were notified of care plan meetings by mail. Residents did not receive notification as far as she was aware. On 06/21/22 at 3:21 P.M. interview with the Administrator revealed the facility used to go around and ask residents if there were any concerns prior to the care conferences held before the COVID pandemic. The Administrator verified residents should be given an opportunity to participate in the care planning process. 3. Review of Resident #45's medical record revealed diagnoses including end stage renal disease, chronic obstructive pulmonary disease, diabetes mellitus, depression, obstructive sleep apnea, heart disease, and history of a heart attack. An annual MDS 3.0 assessment, dated 05/13/22 revealed Resident #45 usually understood others. Resident #45 was assessed as cognitively intact. Review of progress notes, dated 12/18/20 at 9:18 A.M., 03/19/21 at 9:48 A.M., 05/21/21 at 12:37 P.M., 08/20/21 at 9:37 A.M., 11/19/21 at 9:32 A.M., and 05/20/22 at 9:27 A.M. indicated plan of care meetings were held. Family was invited to the meetings and did not attend. On 06/13/22 at 11:01 A.M. interview with Resident #45 revealed he was not invited to participate in setting goals and planning his care. On 06/14/22 at 3:00 P.M. interview with Social Service Designee (SSD) #480 revealed when care conferences were held, families were notified by mail. SSD #480 revealed she was unaware of residents being invited to participate in the meetings. On 06/15/22 at 1:30 P.M. interview with the Director of Nursing (DON) revealed care conferences were geared toward family so they could receive updates from all disciplines. If family wanted a resident to attend, the resident could be included. Families were notified of care plan meetings by mail. Residents did not receive notification as far as she was aware. On 06/21/22 at 3:21 P.M. interview with the Administrator revealed the facility used to go around and ask residents if there were any concerns prior to the care conferences held before the COVID pandemic. The Administrator verified residents should be given an opportunity to participate in the care planning process. 365822 Page 5 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

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 Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #41 and #45, who required staff assistance with activity of daily living care received timely and adequate oral hygiene and/or nail care. This affected two residents (#41 and #45) of five residents reviewed for activities of daily living. Residents Affected - Few Findings include: 1. Review of Resident #41's medical record revealed diagnoses including end stage renal disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), Alzheimer's disease, depression, and chronic pain. On 12/16/21 a physician order was written for oral hygiene every shift and as necessary. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 indicated Resident #41 was usually able to make herself understood and was usually able to understand others. Resident #41 was assessed as moderately cognitively impaired and no rejection of care was documented. The MDS assessment revealed Resident #41 was dependent on staff for transfers and required extensive assistance from staff for personal hygiene. On 06/13/22 at 4:15 P.M. Resident #41 was observed to have a thick film covering her teeth. At the time of the observation, interview with Resident #41 revealed staff did not provide a toothbrush or assist with brushing her teeth. On 06/14/22 at 9:35 A.M. Resident #41's teeth continued to appear unbrushed with a plaque build up noticed on her teeth. On 06/14/22 at 3:10 P.M. interview with Temporary Nursing Assistant (TNA) #466 revealed she observed Resident #41's teeth appeared unclean on 06/13/22 but was unaware of anybody offering to brush Resident #41's teeth. TNA #466 indicated she believed shower aides might have been responsible for brushing residents' teeth. Upon request, TNA #466 searched through two dressers and the nightstand and verified she was unable to locate a toothbrush in the resident's room. On 06/15/22 at 5:30 A.M. observations of Resident #41 revealed the thick film previously noted on her teeth was no longer evident. Review of the facility undated Oral Care policy revealed oral care was to be performed for each resident every shift and as necessary daily. 2. Review of Resident #45's medical record revealed diagnoses including left sided weakness and paralysis following a stroke, end stage renal disease, COPD, diabetes mellitus, CHF, heart disease and history of a heart attack. An annual MDS 3.0 assessment, dated 05/13/22 revealed Resident #45 was understood and was usually able to understand others. Resident #45 was assessed as cognitively intact. The MDS assessment revealed Resident #45 was dependent for transfers and required extensive assistance from staff for personal hygiene. 365822 Page 6 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0677 Level of Harm - Minimal harm or potential for actual harm On 06/13/22 at 11:05 A.M. observation revealed the under side of Resident #45's fingernails appeared black. At the time of the observation, interview with Resident #45 revealed his fingernails were cleaned the other day but they kept getting dirty. On 06/15/22 at 9:05 A.M. the under side of Resident #45's fingernails continued to appear black. Residents Affected - Few On 06/15/22 at 9:08 A.M. interview with the Administrator verified Resident #45's fingernails were not clean. The Administrator stated nail care was supposed to be completed with showers and as necessary. This deficiency substantiates Complaint Number OH00131579. 365822 Page 7 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on record review and interview the facility failed to ensure Resident #10, who exhibited limited range of motion (ROM) received services to increase and/or maintain range of motion. This affected one resident (#10) of 25 residents reviewed and/or interviewed regarding range of motion. Findings include: Review of Resident #10's medical record revealed diagnoses including multiple sclerosis, diabetes mellitus, depression and chronic pain. A plan of care, initiated 06/15/15 revealed Resident #10 was at risk for contractures with a goal for Resident #10 to have no evidence of pain during ROM. Interventions included referring Resident #10 to physical and occupational therapy (dated 06/15/15) but was silent to other interventions to prevent contractures. Review of a restorative referral form, dated 12/11/20 revealed specific instructions for ROM and stretching to both lower extremities and assistive active ROM (AAROM - an exercise in which a manual or mechanical external force assists specific muscles and joints to move through their available excursion)/Passive ROM (gentle movements of a joint or joints through flexion and extension) of the right digits into extension. A restorative program was initiated for active ROM (AROM - exercises performed by an individual to restore or maintain their joint function to its optimal range) for the upper extremities and AAROM to the lower extremities to be provided 5-7 days per week for 15-30 minutes and bed mobility 5-7 days per week for 15-30 minutes. Review of restorative flow records for December 2021 revealed Resident #10 was offered/provided ROM services nine times the entire month. Review of restorative flow records for January 2022 revealed ROM services was offered five times for the month. Review of restorative flow records for February 2022 revealed AROM services were offered six times to the upper extremities per resident request. Review of restorative flow records for March 2022 revealed AROM services were offered six times to the upper extremities per resident request. On 04/01/22 the order for the restorative therapy program for ROM and bed mobility was discontinued. No ongoing evaluation of the program or reason for discontinuation of the program was able to be located. On 04/04/22 a physician order was written for ROM 3-5 times a week for 15-30 minutes by restorative staff. No records were provided to indicate the ROM was offered/provided. The order was discontinued 04/09/22 with no evidence of an evaluation or rationale. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/03/22 indicated Resident #10 was cognitively intact and had functional limitation in range of motion of one lower extremity. 365822 Page 8 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/14/22 at 9:39 A.M. interview with Resident #10 revealed she had difficulty with range of motion (ROM) in her shoulder and legs. Resident #10 indicated she was supposed to get restorative services for ROM but the restorative aide was being given other assignments so she was not receiving ROM on a routine basis. On 06/21/22 at 8:06 A.M. interview with Restorative State Tested Nursing Assistant (STNA) #452 revealed Resident #10 was previously receiving restorative programs but they had been discontinued. STNA #452 indicated she was unsure why the programs were discontinued but knew the facility had to downsize the number of residents with restorative programs because she was frequently given alternate assignments and could not provide the restorative programs as ordered. On 06/22/22 at 11:30 A.M. interview with Licensed Practical Nurse (LPN) #422 revealed she was responsible for overseeing the restorative programs. LPN #422 verified restorative programs were unable to be provided as ordered on a consistent basis because the restorative aide was given alternate assignments. LPN #422 indicated she met with restorative aides to discuss residents but did not do written evaluations of programs. LPN #422 indicated Resident #10's restorative ROM programs were not discontinued due to the services not being needed but because there was nobody to provide the programs. The orders were discontinued in April 2022 because another nurse was supposed to start employment and assume responsibility of the restorative program. LPN #422 planned on restarting the program and educating the new nurse how to input the orders. However, the new nurse did not take the position and the orders were not rewritten. The facility identified seven residents, Resident #2, #8, #22, #41, #43, #45 and #55 as the only residents with current orders for restorative programs. This deficiency substantiates Complaint Number OH00131579. 365822 Page 9 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

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. Based on record review, facility policy and procedure review and interview the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected three residents (#10, #17 and #46) and had the potential to affect all 65 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 08/10/21 with diagnoses including osteomyelitis, incomplete paraplegia, major depressive disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22 revealed Resident #46 was cognitively intact and required two person assistance for bathing. Review of Resident #46's shower records from April 2022 through 06/15/22 revealed showers were scheduled every Monday, Wednesday and Friday. The facility provided documentation of showers completed on 04/05/22, 04/11/22, 04/12/22, 04/18/22, 04/20/22, 04/22/22, 04/27/22, 05/02/22, 05/04/22, 05/13/22, 05/18/22, 05/20/22, 05/30/22, 06/05/22, 06/10/22 and 06/15/22. This reflected instances of Resident #46 not receiving showers on the scheduled days. On 06/14/22 at 11:45 A.M., interview with Resident #46 revealed a concern showers were not provided routinely. The resident voiced he was supposed to receive a shower on 06/13/22 but stated he did not get a shower because the shower aide was too busy to give him a shower. On 06/21/22 at 2:00 P.M. interview with State Tested Nurse Aide (STNA) #460 verified showers were not always completed as scheduled because she was the only designated shower aide for her assigned area and was often pulled to work as an aide the floor. She said being the only shower aide for the unit made it difficult to complete all showers as scheduled. She also stated showers did not get completed by the STNAs on the floor when she was not at the facility. 2. Review of the medical record for Resident #17 revealed an admission date of 06/03/20 with diagnoses including congestive heart failure, type two diabetes mellitus, muscle weakness, and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment, dated 04/0822 revealed Resident #17 was cognitively intact and required one person assistance for bathing. Review of Resident #17's shower records from April 2022 through 06/15/22 revealed showers were scheduled for every Monday and Wednesday. The facility provided documentation of bathing being provided on 04/04/22, 04/06/22, 04/11/22, 04/20/22, 04/25/22, 04/27/22, 05/03/22, 05/05/22, 05/09/22, 05/11/22, 05/18/22, 05/23/22, 06/01/22, 06/06/22, 06/08/22, 06/13/22 and 06/15/22. This reflected large gaps up to nine days between documented showers or bathing activities for the resident. 365822 Page 10 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 06/14/22 at 11:20 A.M. interview with Resident #17 revealed a concern that showers were not provided routinely. The resident was unable to recall the last time she had actually received a shower. On 06/21/22 at 2:00 P.M. interview with State Tested Nurse Aide (STNA) #460 verified showers were not always completed as scheduled because she was the only designated shower aide for her assigned area and was often pulled to work as an aide on the floor. She said being the only shower aide for the unit made it difficult to complete all showers as scheduled. She also stated showers did not get completed by the STNAs on the floor when she was not at the facility. 3. Review of Resident #10's medical record revealed diagnoses including urinary and fecal incontinence, multiple sclerosis, diabetes mellitus, asthma, and major depressive disorder. a. Review of the annual MDS 3.0 assessment, dated 02/04/22 revealed Resident #10 indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. A quarterly MDS 3.0 assessment, dated 06/03/22 indicated Resident #10 was able to make herself understood and was able to understand others. Resident #10 was assessed as cognitively intact. The assessment revealed Resident #10 was totally dependent on staff for transfers and required physical help in part of bathing activity. Review of Resident #10's shower records revealed for April and May 2022 the resident was scheduled to receive a shower three times per week. Review of the bathing documents for April 2022 revealed only two showers were provided the weeks beginning 04/03/22 and 04/10/22 and one shower was provided the week beginning 04/24/22. Review of the May 2022 bathing documents revealed only one shower was provided the week beginning 05/08/22, two showers were provided the week beginning 05/15/22 and no showers were recorded between 05/20/22 and 05/31/22. Review of June 2022 bathing records revealed two showers were scheduled per week, on Monday and Thursday. A notation on 06/08/22 revealed a shower was not given because staff were pulled to the floor. On 06/14/22 at 9:20 A.M. interview with Resident #10 revealed she was supposed to get showers three times a week but sometimes only received one shower. The resident indicated she was also unable to get a bed bath. On 06/21/22 at 10:45 A.M. the Director of Nursing (DON) was interviewed regarding documentation revealing showers were not provided according to the resident's preference. The DON indicated she believed she might be able to find additional documentation to reflect showers were actually provided. On 06/21/22 at 3:21 P.M. the Administrator revealed the facility was unable to find any additional information regarding showers for Resident #10. The resident had not received showers per her preference and the Administrator verified Resident #10 was oriented. b. A plan of care, initiated 06/15/15 revealed Resident #10 was at risk for contractures with a goal for Resident #10 to have no evidence of pain during ROM. Interventions included referring Resident #10 to physical and occupational therapy (dated 06/15/15) but was silent to other interventions to prevent contractures. 365822 Page 11 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of a restorative referral form, dated 12/11/20 revealed specific instructions for ROM and stretching to both lower extremities and assistive active ROM (AAROM - an exercise in which a manual or mechanical external force assists specific muscles and joints to move through their available excursion)/Passive ROM (gentle movements of a joint or joints through flexion and extension) of the right digits into extension. A restorative program was initiated for active ROM (AROM - exercises performed by an individual to restore or maintain their joint function to its optimal range) for the upper extremities and AAROM to the lower extremities to be provided 5-7 days per week for 15-30 minutes and bed mobility 5-7 days per week for 15-30 minutes. Review of restorative flow records for December 2021 revealed Resident #10 was offered/provided ROM services nine times the entire month. Review of restorative flow records for January 2022 revealed ROM services was offered five times for the month. Review of restorative flow records for February 2022 revealed AROM services were offered six times to the upper extremities per resident request. Review of restorative flow records for March 2022 revealed AROM services were offered six times to the upper extremities per resident request. On 04/01/22 the order for the restorative therapy program for ROM and bed mobility was discontinued. No ongoing evaluation of the program or reason for discontinuation of the program was able to be located. On 04/04/22 a physician order was written for ROM 3-5 times a week for 15-30 minutes by restorative staff. No records were provided to indicate the ROM was offered/provided. The order was discontinued 04/09/22 with no evidence of an evaluation or rationale. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/03/22 indicated Resident #10 was cognitively intact and had functional limitation in range of motion of one lower extremity. On 06/14/22 at 9:39 A.M. interview with Resident #10 revealed she had difficulty with range of motion (ROM) in her shoulder and legs. Resident #10 indicated she was supposed to get restorative services for ROM but the restorative aide was being given other assignments so she was not receiving ROM on a routine basis. On 06/21/22 at 8:06 A.M. interview with Restorative State Tested Nursing Assistant (STNA) #452 revealed Resident #10 was previously receiving restorative programs but they had been discontinued. STNA #452 indicated she was unsure why the programs were discontinued but knew the facility had to downsize the number of residents with restorative programs because she was frequently given alternate assignments and could not provide the restorative programs as ordered. On 06/22/22 at 11:30 A.M. interview with Licensed Practical Nurse (LPN) #422 revealed she was responsible for overseeing the restorative programs. LPN #422 verified restorative programs were unable to be provided as ordered on a consistent basis because the restorative aide was given alternate assignments. LPN #422 indicated she met with restorative aides to discuss residents but did not do written evaluations of programs. LPN #422 indicated Resident #10's restorative ROM programs were not discontinued due to the services not being needed but because there was nobody to provide the programs. 365822 Page 12 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The orders were discontinued in April 2022 because another nurse was supposed to start employment and assume responsibility of the restorative program. LPN #422 planned on restarting the program and educating the new nurse how to input the orders. However, the new nurse did not take the position and the orders were not rewritten. The facility identified seven residents, Resident #2, #8, #22, #41, #43, #45 and #55 as the only residents with current orders for restorative programs. Review of the undated facility Staff policy and procedure revealed staffing was per facility needs and could vary depending on census and acuity levels of patients. Staffing was assessed on a shift by shift basis and adjusted accordingly. This deficiency substantiates Complaint Number OH00131579. 365822 Page 13 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 6.25% and included two medication errors of 32 medication administration opportunities. This affected two residents (#38 and #58) of seven residents observed for medication administration. Residents Affected - Few Findings include: 1. On 06/15/22 at 6:06 A.M., Licensed Practical Nurse (LPN) #604 was observed preparing and administering Lantus insulin to Resident #58 via an insulin pen. The pen was not primed after the needle was applied. The pen was set on 28 units for administration into the right lower quadrant of the abdomen. On 06/15/22 at 6:07 A.M. interview with LPN #604 verified she had not primed the insulin pen prior to administering the insulin. LPN #604 indicated she believed the pen only needed primed when the pen was originally opened. Review of the facility undated policy titled Insulin Flex Pen Policy revealed after attaching the needle to the flex pen, two units air shot was to be prepared before each injection, making sure no air bubbles collected in the cartridge by tapping lightly with the finger. Keeping the needle pointed upward, the button was to be pushed until two units of insulin was released and the indicator returned to 0. A drop of insulin should appear at the needle tip. If not the procedure was to be repeated prior to turning the dose selector to the number of units to be injected. 2. On 06/15/22 at 8:47 A.M., LPN #430 was observed preparing and administering medication to Resident #38. While preparing the medication, LPN #430 stated ordered Megace was not available for administration. Review of Resident #38's Medication Administration Record (MAR) revealed an order for Megace ES (treats loss of appetite) 400 milligrams (mg) every day. When the MAR was reviewed on 06/15/22 at 9:15 A.M. it indicated Megace ES had been administered. On 06/15/22 at 10:40 A.M. interview LPN #430 verified the Megace ES had not been located or administered as ordered during the above observation. Review of the facility undated Medication Administration policy revealed medications were to be administered in accordance with written orders of the prescriber. 365822 Page 14 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure all medications were properly stored and failed to ensure insulin pens were dated when opened. This affected five residents (#19, #23, #46, #53 and #58) of eight residents reviewed for medication administration and/or involved in observations of three medication carts and one medication room. The facility census was 65. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 08/10/21 with diagnoses including osteomyelitis, incomplete paraplegia, major depressive disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the physician's orders for June 2022 revealed an order for the narcotic pain medication, Norco 5-325 milligrams (mg) one tablet every eight hours as needed for pain. Review of the medication administration record (MAR) revealed staff documented the resident was administered the Norco on 06/14/22 at 11:08 A.M. On 06/14/22 at 11:45 A.M. observation of Resident #46's room revealed a single white pill in a plastic cup on the bedside table. At the time of observation, interview with Resident #46 revealed the pill was his pain medication and he was saving it for later. Resident #46 stated the nurse provided the medication with the rest of his medications that morning but he did not take that one when he took the rest of his medications. On 06/14/22 at 11:57 A.M. interview with Registered Dietitian (RD) #427 verified there was one pill in a cup on Resident #46's bedside table. On 06/21/22 at 12:57 P.M. interview with the Director of Nursing (DON) revealed the facility does not have any residents who self-administer medications. Review of the facility undated policy titled Medication Administration revealed residents would be observed after medication administration to ensure the dose was completely ingested. 2. On 06/15/22 at 5:05 A.M., Licensed Practical Nurse (LPN) #604 was observed entering room [ROOM NUMBER] leaving the medication cart unlocked and unsupervised. A medication cup with medication in it was observed on top of the medication cart. When LPN #604 returned to the medication cart at 5:14 A.M. she verified she had left Resident #19's medication on top of the cart unattended. LPN #604 stated she should have placed the medication for Resident #19 into the medication cart prior to leaving the cart unattended. LPN #604 verified the cart was left unlocked when she went into room [ROOM NUMBER]. Review of Resident #19's Medication Administration Record (MAR) and physician orders revealed medications scheduled for 6:00 A.M. administration included Gabapentin (used to treat neuropathic pain), Hydralazine (used to treat hypertension) and Clonidine (used to treat hypertension). 365822 Page 15 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility undated Medication Administration policy revealed during administration of medications the medication cart was kept closed and locked when out of sight of the nurse. No medications were to be kept on top of the cart. 3. On 06/15/22 at 6:06 A.M. while observing LPN #604 prepare medication for Resident #58, it was noted the insulin Lispro pen did not have a date recorded when it was opened. This was verified by LPN #604 at the time of observation. On 06/16/22 at 11:13 A.M. observations were made of two medication carts on Unit I with LPN #444. LPN #444 verified an opened Lantus insulin pen for Resident #53 was not dated when it was opened. The pen was delivered on 06/13/22. LPN #444 verified Resident #23 had an opened/undated Lantus insulin pen which had been delivered 05/17/22. The insulin pens had an area to record the date opened and instructions that once opened, the pen should be discarded after 28 days. On 06/16/22 at 11:56 A.M., LPN #444 verified the above insulin pens were to be discarded 28 days after opening. Review of the facility Medication Storage in the Facility policy, revised January 2018 revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy indicated medication rooms, carts and medication supplies were to be locked when not attended by persons with authorized access. Certain medication or package types, such as multiple dose injectable vials, once opened, required an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. When the original seal of a manufacturer's container or vial was initially broken, the container or vial would be dated. The nurse should place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container would be 30 days unless the manufacturer recommended another date or regulations/guidelines required different dating. The nurse was to check the expiration date of each medication before administering it. 365822 Page 16 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

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 closed record review and interview the facility failed to promptly notify the physician or nurse practitioner of laboratory results outside the clinical reference range for Resident #61. This affected one resident (#61) of five residents reviewed for unnecessary medication use. Findings include: Review of the closed medical record for Resident #61 revealed the resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic obstructive pulmonary disorder and aphasia. Review of the laboratory testing results, dated 05/11/22 revealed the resident had a critical lab, hemoglobin of 6.9 (low) (normal range 12.1 to 15.1). Review of laboratory results dated [DATE] revealed the resident's hemoglobin remained critically low at 7.6. Review of the progress note, dated 05/11/22 revealed no evidence the physician (MD) or the certified nurse practitioner (CNP) were notified of the critical lab on this date. A progress note, dated 05/16/22 revealed the CNP was notified and the resident was sent to the hospital at that time. The resident did not return to the facility. On 06/21/22 at 4:53 P.M. interview with CNP #602 revealed she was not sure if it was her or the other CNP who would have been contacted regarding Resident #61's laboratory testing. The CNP revealed Resident #61's hemoglobin typically ran low and thought one of the CNP's had recommended to monitor and re-check in a week. She stated on 05/16/22 the resident's white blood count was high which was why the resident was transferred to the hospital on [DATE]. CNP #602 verified there was a lack of documentation to support the notification of the 05/11/22 critical labs On 06/22/22 at 8:24 A.M. interview with the Director of Nursing (DON) verified there was no evidence the MD or CNP were informed of Resident #61's critical lab on 05/11/22. 365822 Page 17 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, record review and interview the facility failed to ensure resident medical records were complete and accurate. This affected three (#41, #45 and #62) of 21 residents whose medical records were reviewed. Findings include: 1. Review of Resident #41's medical record revealed diagnoses including end stage renal disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), Alzheimer's disease, depression, and chronic pain. On 12/16/21, a physician order was written for oral hygiene every shift and as necessary. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 indicated Resident #41 was usually able to make herself understood and was usually able to understand others. Resident #41 was assessed as moderately cognitively impaired. No rejection of care was documented. The MDS assessment revealed Resident #41 was dependent on staff for transfers and required extensive assistance from staff for personal hygiene. Review of the June 2022 Treatment Administration Record (TAR) indicated nurses documented the completion of oral care every shift and as necessary. On 06/13/22 at 4:15 P.M. Resident #41 was observed to have a thick film covering her teeth. At the time of the observation, interview with Resident #41 revealed staff did not provide a toothbrush or assist her with brushing her teeth. On 06/14/22 at 9:35 A.M., Resident #41's teeth continued to appear unbrushed with a plaque build up noticed on her teeth. On 06/14/22 at 3:10 P.M., Temporary Nursing Assistant (TNA) #466 revealed she observed Resident #41's teeth appeared unclean on 06/13/22 but was unaware of anybody offering to brush Resident #41's teeth. Upon request, TNA #466 searched through two dressers and the nightstand and verified she was unable to locate a toothbrush. The resident's medical record was not accurate as the resident was not observed to have a toothbrush provided to her, yet staff documented the completion of oral hygiene every day. 2. Review of Resident #45's medical record revealed diagnoses including end stage renal disease and dependence on renal dialysis. A physician order was written for LiquaCel (protein supplement) 30 milligrams/milliliter to be administered every day as a supplement for renal purposes. The order did not indicate the amount of LiquaCel to be administered. Review of the June 2022 Medication Administration Record (MAR) indicated LiquaCel was administered every day from 06/15/22 through 06/21/22, including by Registered Nurse (RN) #491 on 06/21/22. 365822 Page 18 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0842 Level of Harm - Minimal harm or potential for actual harm On 06/21/22 at 11:10 A.M. RN #491 was asked for clarification of the amount of LiquaCel to be administered. RN #491 stated the LiquaCel had not been delivered yet and she had not had to administer it. After checking the medication cart, RN #491 verified there was no LiquaCel. RN #491 verified she had put the order for LiquaCel into the electronic health record. RN #491 verified the order was incomplete as it did not indicate the amount to be administered. Residents Affected - Few On 06/21/22 at 12:55 P.M. interview with the Director of Nursing (DON) revealed the LiquaCel was administered at dialysis and provided a dialysis communication sheet dated 06/14/22 which indicated 30 milliliters (ml) of LiquaCel was provided at dialysis. The communication sheet did not indicate an order for LiquaCel to be administered every day. The DON stated RN #491 erroneously wrote the order for LiquaCel and it was not being administered by staff. 3. Review of the closed medical record for Resident #62 revealed an admission date of 04/09/22 and discharge date of 05/04/22. Resident #62 had diagnoses including end stage renal disease, type two diabetes mellitus, anemia in chronic kidney disease and adult failure to thrive. Further review of the closed medical record revealed no discharge planning information was available for review in the electronic health record. On 06/16/22 at 9:00 A.M. review of the assessment titled Social History, created 04/11/22 and not signed or locked, revealed the discharge planning section was blank. On 06/16/22 at 2:36 P.M. interview with Social Services Designee (SSD) #480 indicated discharge planning was discussed at care conferences. Review of the progress notes revealed the care conference progress notes did not indicate discharge planning was discussed. SSD #480 verified the progress notes did not mention discharge planning. On 06/16/22 at 3:00 P.M. interview with the Director of Nursing (DON) revealed discharge planning information was located in the Social History assessment. Review of the Social History assessment revealed it was signed and locked on 06/16/22 at 2:51 P.M. and the discharge planning information was filled out. On 06/16/22 at 3:29 P.M., interview with SSD #480 verified the Social History assessment was created on 04/11/22 and was signed and locked on 06/16/22 at 2:51 P.M. SSD #480 denied the assessment had been altered to include discharge planning documentation. 365822 Page 19 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on review of Quality Assessment and Assurance (QAA) meeting attendance sheets and interview the facility failed to ensure the required members of the QAA committee participated in meetings to address QAA activities. This had the potential to affect all 65 residents. Residents Affected - Many Findings include: Review of Quality Assurance (QA) attendance sheets for meetings held on 07/13/21, 10/19/21, 01/18/22, and 04/12/22 revealed each of the meetings were held virtually by Go-To Meeting. There was no evidence of physician participation in the meetings. On 06/14/22 at 1:15 P.M. interview with the Director of Nursing (DON) verified there was no physician who participated in the QAA meetings. However, she and the Administrator did discuss the meeting afterward with the medical director. On 06/14/22 at 1:20 P.M. interview with the Administrator verified a physician did not actively participate during the facility QAA meetings. The Administrator indicated because she and the DON met with the medical director to review the meeting afterward, she considered that as participation. 365822 Page 20 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. On 06/15/22 at 6:00 A.M., Licensed Practical Nurse (LPN) #604 was overheard informing Resident #167 that she was going to check his blood sugar and informed him of the results. LPN #604 left Resident #167's room with a glucometer and placed it on the top of the medication cart then proceeded to Resident #58's room where she checked his blood glucose level with the same glucometer without disinfecting it. Residents Affected - Many On 06/15/22 at 6:07 A.M. interview with LPN #604 verified she had not disinfected the glucometer between resident uses but should have. Review of the Center for Disease Control guidelines: Infection Prevention during Blood Glucose Monitoring and Insulin Administration revealed whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use. This deficiency substantiates Complaint Number OH00131579. Based on observation, record review, facility policy and procedure review, Centers for Disease Control (CDC) guidance and interview the facility failed to maintain proper infection control practices during blood glucose monitoring and for residents in quarantine and/or isolation for COVID-19 to decrease the risk of spreading infection, including COVID-19. This affected one resident (#58) of two residents observed for blood glucose monitoring, six residents (#4, #40, #43, #12, #211 and #212) reviewed related to COVID-19 and had the potential to affect all 65 residents residing in the facility. Findings include: 1. During the annual survey, the facility identified Resident #12 as the only resident in isolation for COVID-19 (the resident had a positive test). Resident #4, #40, #43, #12, #211 and #212 were identified to be in quarantine related to potential exposure to Resident #12, however as of 06/13/22, none of these six residents had tested positive for COVID-19. Review of the medical record for Resident #12 revealed an admission date of 03/17/22 with diagnoses including pressure ulcer of sacral region, dementia without behavioral disturbance, cognitive communication deficit and personal history of COVID-19 (dated 06/10/22). Review of the care plan, dated 06/11/22 revealed Resident #12 was at-risk for respiratory complications related to a diagnosis of COVID-19. Interventions included isolation per the facility's protocol and personal protective equipment (PPE) per the facility's protocol. Review of the progress note, dated 06/13/22 at 11:40 A.M. revealed Resident #12 had tested positive for COVID-19. A corresponding physician's order, dated 06/12/22 revealed the resident had an order for contact and droplet isolation (for COVID-19). On 06/13/22 at 11:50 A.M. State Tested Nursing Assistant (STNA) #603 was observed to exit Resident #12's room. The STNA was wearing an N95 mask with a surgical mask over top of it. Upon exiting the room, the STNA did not remove/discard either mask and did not cleanse her eye goggles. STNA #603 then applied an isolation gown and gloves and entered the room of Resident #211 and #212 wearing the same surgical and N95 mask. Resident #211 and #212 were in quarantine for COVID-19 as the residents had 365822 Page 21 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many resided on the same unit as Resident #12, but did not have positive COVID-19 testing. Resident #212 had not been vaccinated for COVID-19. On 06/13/22 at 11:55 A.M. interview with STNA #603 verified she did not discard or change her surgical mask/ N95 mask or cleanse her eye protection after exiting Resident #12's room. The STNA revealed Resident #12 was in isolation for COVID-19 and other residents (including Resident #211 and #212) were in quarantine for COVID-19 but not isolation. STNA #603 revealed staff changed changed their surgical masks a few times throughout the shift and wore the same N95 mask for the entire shift. STNA #603 revealed there were no set time for changing masks. In addition, STNA #603 revealed sanitizing wipes for goggles were located in the storage area on the unit and staff sanitized their goggles whenever they had a free moment to do so, but there was no set time for sanitizing goggles. On 06/13/22 at 12:39 P.M. interview with STNA #603 and Nursing Assistant (NA) #414 revealed they spend a cumulative time of more than 15 minutes in each resident room (those in isolation and in quarantine) throughout their shift. On 06/15/22 at 8:04 A.M. STNA #600 was observed to exit Resident #12's room. The STNA failed to discard or change her N95 mask upon exiting the resident's room. On 06/15/22 at 8:09 A.M. interview with STNA #600 verified she did not change her N95 mask after exiting Resident #12's room and stated N95 masks do not get changed between rooms for residents in isolation and quarantine. The STNA revealed Resident #12 was the only resident with confirmed COVID-19. Other residents had been placed in quarantine due to residing on the same unit as Resident #12. On 06/15/22 between 9:22 A.M. and 9:25 A.M. Social Services Designee (SSD) #480 was observed to enter the rooms of Resident #4, #40 and #43 wearing a surgical mask and no N95 mask or respirator. These three residents had orders for contact/droplet isolation and were in quarantine for COVID-19, but had not tested positive for COVID-19. On 06/15/22 at 9:26 A.M. interview with SSD #480 verified she did not wear an N95 mask when entering the above resident rooms. SSD #480 also confirmed each resident was currently in quarantine for COVID-19 due to potential exposure from residing on the same unit as Resident #12 (who had tested positive). On 06/16/22 at 11:52 A.M. interview with the Director of Nursing (DON) revealed Resident #12 tested positive for COVID-19 on 06/10/22 via an antigen testing. The DON revealed the resident's isolation was discontinued on 06/16/22. On 06/16/22 at 1:30 P.M. interview with Local Health Department DON (DLHD) #601 revealed facilities were expected to report any positive test (PCR or rapid) to the LHD. DLHD #601 denied knowledge of the positive COVID case at the facility. DLHD #601 revealed a PCR test had to be conducted within 24 hours in order to be accurate. DLHD #601 revealed the recommendation was for a resident who tested positive for COVID-19 to be in isolation for ten days. The roommate or anyone who came in contact with a COVID-19 positive case was to quarantine for ten days. On 06/21/22 at 10:21 A.M. a phone interview with husband of Resident #12 revealed the resident had symptoms of COVID-19, prior to testing positive, including congestion, headaches and sore muscles. Review of the facility policy titled Initiation of Isolation Precautions, dated 01/01/21 revealed 365822 Page 22 of 23 365822 06/23/2022 Briarfield Manor 461 South Canfield Niles Road Youngstown, OH 44515

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many all personal protective equipment (PPE), including but not limited to disposable isolation gowns, masks, and gloves, should be used once and discarded in either the trash or the used linen receptacle before leaving an isolation room. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 02/02/22 revealed the following: Source control options for health care professionals (HCP) include a NIOSH-approved N95 or equivalent or higher-level respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated). When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. 365822 Page 23 of 23