Health inspection·January 24, 2022

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on resident funds review and interview the facility failed to ensure Resident #3's funds were safeguarded, properly managed and not returned to the Treasurer of Ohio following stimulus money received by the resident. This affected one resident (#3) of 43 residents identified to have personal funds managed by the facility. Residents Affected - Few Findings include: On 01/20/22 at 5:20 P.M. review of the resident personal fund accounts with the Administrator, who was onsite at the facility and Business Office Manager (BOM) #149 via phone revealed the following: Resident #3 was reviewed for spend down notice. Record review revealed the resident's representative, her sister was sent a spend down letter on 11/12/21. The letter indicated Resident #3's personal funds exceeded the $2000.00 Medicaid allowance. The resident trust had a balance of $3957.52. The letter advised that if the account was over the $2000.00 limit, the resident would no longer qualify for Medicaid and indicated due to the fact this balance was over the $2000.00 limit, please take the necessary steps to spend down the money immediately on anything the resident might need. Otherwise the money would have to be lump sum returned to the State Medicaid office. Review of the account revealed on 12/31/21 there was $3981.66 in the account. On the same date a lump sum of $2481.29 was returned to the State Treasurer of Ohio drawing the account down to $1500.37. On 01/20/22 at 5:20 P.M. interview with BOM #149 revealed she believed there was a law requiring residents to spend their stimulus money within a year of getting the money so she sent $2481.29 from Resident #3 to the State Treasurer of Ohio on 12/31/21 which gave the resident a remaining balance of $1500.00. She said since she usually sends a spend down letter at $1500.00 she drew the account down to $1500.00 instead of the allowed $2000.00. BOM #149 indicated the resident received $600.00 of stimulus money on 01/28/21, so the year to spend it would be up 01/28/22. On 04/07/21 the resident received $1400.00 in stimulus which would have needed spent by 04/07/22. BOM #149 then realized the resident could have kept the money since a year had not lapsed. BOM #149 revealed she had spoken to the residents' sister last summer and asked her what the money could be spent on. She told her if it was not spent by December 2021 she would need to send it back to the State. On 06/30/21 $805.44 was spent for resident personal needs from Senior Shopping Service (a quilt, sheets, blankets and clothes were purchased). On 08/11/21 $198.41 was spent on resident personal needs (toiletries, decorations and a lamp). BOM #149 revealed Resident #3's sister sent an estimate for bracelets for Resident #3 to purchase to give the grandchildren as a memory from her. BOM #149 said she called the county and they said this was too extravagant and she couldn't spend her money on bracelets for the grandchildren. BOM #149 revealed she did not follow up with the resident's sister in December 2021 before Page 1 of 26 365975 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sending the money back. The BOM again verified the money did not need sent back yet and the resident's account did not need to be drawn down to $1500.00. In addition, the BOM was not aware the one year timeline to spend the money did not start until the federal emergency was lifted. BOM #149 indicated she was following instructions from the corporate office. On 01/20/22 at 5:57 P.M. interview with Resident #3's sister revealed she had spoken to the lady who handled the resident's money last summer but had not spoken to her since. Resident #3's sister revealed she was aware the money would have to be sent back to the State if it wasn't spent. Resident #3's sister revealed she wanted to use the money to purchase gifts for the resident's grandchildren since they could not think of what else to buy for the resident, but had been told this was not an allowable purchase. The resident's sister said she did purchase some items for the resident for Christmas and had sent receipts to the BOM the end of November or beginning of December but had not been reimbursed as of this time. The facility identified 43 residents, Resident #1, #2, #3 #4, #5, #7, #8, #10, #12, #13, #14, #17, #20, #22, #23, #25, #26, #28, #29, #35, #36, #37, #38, #40, #41, #42, #43, #44, #51, #52, #53, #56, #57, #58, #60, #63 #64, #70, #71, #72, #73, #74 and #475 who had personal fund accounts managed by the facility. The facility did not provide a spend down policy during the annual survey process for review. 365975 Page 2 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

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. Based on observation, record review and interview the facility failed to ensure all resident rooms were in good repair and properly cleaned. This affected four residents (#60, #35, #19 and #74) of 77 residents residing in the facility. Findings include: 1. On 01/18/22 at 1:23 P.M. observation of Resident #35 and #60's shared room revealed a large gouge in the wall approximately three inches by one foot. On 01/18/22 at 2:01 P.M. interview with Resident #60 revealed concerns her room was dirty. Observation during the interview revealed dust around the base board, a piece of paper and wrappers among other dirt on the floor near the resident's television. On 01/19/22 at 8:23 A.M. observation of Resident #60 and Resident #35's room revealed the floor had not been cleaned and the same dirt as previously observed on 01/18/22 was still present. Interview with Resident #60 at the time of the observation confirmed the room had not been swept since yesterday. On 01/19/22 at 2:04 P.M. the condition of the resident's room remained the same. There was dust, pieces of rubber and papers on the floor. Interview with both Resident #60 and Resident #35 confirmed the observation. On 01/19/22 at 3:09 P.M. interview with Housekeeper #108 revealed she had completed her assignment for the day. During the interview, Housekeeper #108 revealed she was able to clean all the resident's room with no concerns/issues. On 01/19/22 at 3:11 P.M. observation of Resident #60 and resident #35's room with Housekeeper #108 verified the room was dirty. No additional information was provided as to why the room had not been properly cleaned. On 01/19/22 at 3:22 P.M. interview with Maintenance #184 revealed he did a walk through and identified areas of the facility in resident rooms where walls needed repaired. Maintenance #184 indicated Resident #60 and Resident #35's bathroom wall needed repaired but stated this had not yet been completed. The facility provided Room to Room Inspection Sheets, dated 11/17/21 that identified Resident #60 and Resident #35's room had walls that needed patched and painted in the bathroom and door jams that needed touched up. On 01/19/22 at 3:45 P.M. interview with Maintenance #184 revealed on 11/17/21 the maintenance men from two sister facilities went with him through the building and identified things that needed repaired. However, as of this time he had not gotten to all the rooms (including Resident #60 and Resident #35's room). Maintenance #184 verified the paint and plaster damage in the rooms was noted over two months ago and had not been addressed. 2. On 01/18/22 at 5:44 P.M. observation of Resident #19 and Resident #74's room revealed the wall to the right side of bed B near the bedside table had an area where the drywall was out an approximately three inch by one inch space. There was a six inch by six inch area behind the bed where the 365975 Page 3 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some drywall and paint were off. There was a three inch by four inch piece of dry wall cut out between the two beds in the room. On 01/19/22 at 3:22 P.M. interview with Maintenance #184 revealed he did a walk through and identified areas of the facility in resident rooms that needed repaired. Maintenance #184 indicated he was aware of damage in Resident #19 and Resident #74's room but had not been able to fix it. The facility provided Room to Room Inspection Sheets, dated 11/17/21 that identified Resident #19 and Resident #74's room required patching by the night stand and by Bed B and touch up door jams On 01/19/22 at 3:45 P.M. interview with Maintenance #184 revealed on 11/17/21 the maintenance men from two sister facilities went with him through the building and identified things that needed repaired. However, as of this time he had not gotten to all the rooms (including Resident #19 and Resident #74's room). Maintenance #184 verified the paint and plaster damage in the rooms was noted over two months ago and had not been addressed. 365975 Page 4 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure residents and/or resident representatives received bed hold notification prior to transfer to the hospital. This affected two residents (#74 and #76) of two residents reviewed for hospitalization. Findings include: 1. Review of Resident #76's medical record revealed an admission date of 09/30/21 with diagnoses including diabetes, congestive heart failure and hypertension. Further review of the medical record revealed the resident was hospitalized from [DATE] through 11/11/21. The resident returned to the facility on [DATE]. The medical record did not contain evidence the resident or resident representative were notified of the facility bed hold procedure. Further review of the medical record revealed the resident was hospitalized on [DATE] and did not return to the facility. The medical record did not contain evidence the resident or resident representative were notified of the facility bed hold policy and procedure. On 01/20/22 at 2:09 P.M. interview with the Administrator verified the facility did not provide the resident or resident representative notification of the facility bed hold procedures. Review of the facility Bed Hold Policy and Procedure, dated 08/24/18 revealed bed hold notices should be provided at the time of the transfer, or in the case of an emergency, within 24 hours of the transfer. If sending the bed hold notice by mail to a resident representative, a progress note should be written documenting verbal notification of the transfer and the bed hold should notice should be sent via certified mail. 2. Review of Resident #74's medical record revealed the resident had diagnoses including sepsis, chronic respiratory failure with hypoxia, neuromuscular dysfunction of the bladder, tracheostomy, gastrostomy, hypothyroidism, cerebral palsy, spina bifida, scoliosis, Type 2 diabetes, anemia, hypertension, constipation, dependence on oxygen, ileus, mild protein calorie malnutrition, esophagitis, and dependence on ventilator. Review of resident hospitalizations revealed the resident had been transferred to the hospital eight times since August 2021, on 08/30/21, 09/14/21, 09/23/21, 09/29/21, 10/06/21, 10/13/21, 10/27/21 and 11/26/21. There was no evidence the facility provided a written notice which specifies the duration of the bed-hold policy upon transfer from the facility. On 01/20/22 at 1:45 P.M. interview with the Administrator revealed there were no bed hold letters provided/sent out from the business office after September 2021. The Administrator verified the bed hold notices had not been provided for Resident #74. Review of the facility Bed Hold Policy and Procedure, dated 08/24/18 revealed bed hold notices should be provided at the time of the transfer, or in the case of an emergency, within 24 hours of the 365975 Page 5 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0625 Level of Harm - Minimal harm or potential for actual harm transfer. If sending the bed hold notice by mail to a resident representative, a progress note should be written documenting verbal notification of the transfer and the bed hold should notice should be sent via certified mail. Residents Affected - Few 365975 Page 6 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #65 and Resident #69, who required staff assistance for activities of daily living received timely and adequate assistance with oral care and/or showers. This affected two residents (#65 and #69) of two residents reviewed for activities of daily living. Residents Affected - Few Findings include: 1. Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including constipation, cognitive communication disorder, dysphagia, unexpected lack of expected normal physiological development in childhood, hypertension, oxygen dependent, anemia, diverticulosis, scoliosis, angina pectoris, bilateral cataracts, Alzheimer's disease, and Type 2 diabetes. Review of the 01/18/21 Activity of Daily Living (ADL) plan of care revealed the resident may require assistance with ADL's and may be at risk of developing complications associated with decreased ADL self-performance. Interventions included I can perform oral care with assist. The 02/05/21 plan of care for dentition revealed the resident had impaired dentition and was at risk for oral problems related to natural teeth. Interventions included to provide resident with all necessary items to perform adequate oral care (i.e. toothbrush, toothettes, toothpaste, denture holder and cleansers, mouthwash, and mouth moisturizers as needed). Review of the 12/24/21 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making with short and long term memory problems, disorganized thinking, and inattention. The resident was not assessed to have hallucinations or delusions. The assessment revealed the resident required extensive assistance from two staff for bed mobility, was totally dependent from two staff for transfers and did not ambulate. The assessment revealed the resident was totally dependent from one staff for locomotion on the unit and dressing, required staff supervision set up assistance for eating, extensive assistance from two staff for toilet use, was totally dependent from one staff for personal hygiene and totally dependent from one staff for bathing. The assessment revealed the resident had no upper or lower extremity functional impairment and utilized a wheelchair. On 01/18/22 at 3:00 P.M. observation of Resident #65 revealed the resident's teeth had white debris around gum line and a large area of white debris on her upper right teeth. On 01/19/22 at 8:40 A.M. observation of Resident #65 revealed the white debris remained around the resident's teeth, appeared as they were yesterday between the top right teeth. Review of the STNA TASK in point click care revealed the resident was to have oral care provided each shift. In the last 30 days documentation, staff documented once a day either the resident self provided, staff provided or resident refused oral care on 12/22/21/ 12/23/21, 12/24/21, 12/25/21, 12/28/21, 12/29/21, 12/30/21, 12/31/21, 01/01/22, 01/02/22, 01/05/22, 01/06/22, 01/07/22, 01/11/22, 01/12/22, 01/13/22 and 01/15/22. There was no documentation of oral care being provided twice a day. There was no evidence of oral care being provided or offered on 12/27/21, 01/08/22, 01/09/22, 01/10/22, 01/16/22, 01/17/22 or 01/18/22. 365975 Page 7 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/19/22 at 3:20 P.M. interview with State Tested Nursing Assistant (STNA) #111 revealed midnight shift said they bathed the resident last night and oral care was to be part of a bath or shower. The STNA revealed she had not ever provided oral care on day shift to the resident because the resident was a night shift bath. STNA #111 looked in the resident's bedside table, bathroom and closet and could not find any toothbrush, emesis basin or toothpaste for the resident. STNA #111 verified the resident's teeth had debris around them. 2. Review of the medical record for Resident #69 revealed an admission date on 12/20/21 with diagnoses including muscle weakness, contractors, needs for assistance with personal care, spinal muscular atrophy and morbid obesity. Review of the quarterly MDS 3.0 assessment, dated 12/21/21 revealed Resident #69 required total physical assistance from two persons for bathing. Review of the facility provided shower schedule revealed Resident #69 was to receive showers on Sunday, Wednesday and Friday during day shift. Review of the facility provided shower/bath skin sheets revealed from 12/20/21 through 01/20/22 Resident #69 only received showers or bed baths on 12/22/21, 12/26/21, 12/31/21, 1/07/22, 01/09/22 and 01/12/22. On 01/18/22 at 4:32 P.M. interview with Resident #69 revealed she does not always receive showers or baths on her scheduled days. During a follow up interview on 01/19/22 at 12:36 P.M. Resident #69 revealed she asked for a shower today but the staff had not yet provided her one. On 01/20/22 at 9:35 A.M. interview with Resident #69 revealed STNA #155 told her she did not have time to give her a shower yesterday after she requested one. On 01/20/22 at 9:39 A.M. interview with STNA #155 confirmed she was not able to complete Resident #69's shower on her scheduled day (01/19/22) due to being very busy that day and Resident #69 requiring a two person physical assist to complete the shower. On 01/20/22 at 9:51 A.M. interview with Director of Nursing (DON) #103 confirmed Resident #69 had not been getting her showers as scheduled. DON #103 revealed the facility does not have a policy addressing showers. 365975 Page 8 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 urinary drainage bags were maintained without potential for contamination to decrease the risk of urinary tract infections and/or failed to ensure resident catheter orders were comprehensive and implemented as written. This affected two residents (#7 and #60) of two residents reviewed for urinary/indwelling catheters. The facility identified six residents with urinary catheters. Findings include: 1. Review of Resident #7's medical record revealed an admission date of 08/09/19 with diagnoses including hypertension, benign prostate hyperplasia (enlarged prostate gland), obstructive and reflux uropathy (a blockage in the urinary tract). Review of the alteration in elimination due to a urinary catheter related to obstructive uropathy and urinary retention plan of care initiated 08/14/19 revealed interventions including change urinary catheter as ordered and as needed. Review of the non-compliance related to resistant to personal care, personally places catheter bag on the floor, close to himself, so that he can visualize the amount of urine in the bag easily plan of care implemented 09/20/19 revealed interventions including document educational attempts made with resident in relation to compliance, educate resident on negative outcomes related to non-compliance and notify the physician of non-compliance. Review of the physician orders dated 08/10/21 revealed to change the #16 french urinary catheter (no balloon size indicated) and urinary/catheter drainage bag as needed for signs and symptoms of infection, system compromise or blockage due to urinary retention due to obstructive uropathy and provide catheter care every shift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/22/21 revealed the resident was cognitively intact and was independent or required supervision with activities of daily living. The resident had an indwelling catheter and was continent of bowel. Lastly, the resident did not have any rejection of care during the assessment period. Review of the progress note, dated 10/17/21 at 1:04 P.M. revealed Foley (indwelling) catheter was changed per resident request with immediate urine return. A scant amount of bright red blood was noted and the resident tolerated well. A #16 french Foley catheter with a 30 cubic centimeter (cc) balloon was inserted. Review of the progress note revealed on 10/17/21 at 3:00 P.M. the resident complained of severe abdominal pain and the nurse withdrew 30 cc from the balloon of the Foley catheter and attempted to manipulate the Foley for comfort. At that time a profuse amount of blood was noted to be flowing from the resident's penis. Pressure was held by the nurse and 911 was called. The resident left the facility with Emergency Medical Transport at 3:07 P.M. Further review of the progress note, dated 10/17/21 at 6:48 P.M. revealed the emergency room was able to get the bleeding to stop and a new Foley catheter was inserted with a scant amount of bleeding 365975 Page 9 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few noted. The urine was flowing freely and the resident was awaiting transport back to the facility. On 10/17/21 at 9:05 P.M. the resident returned from the hospital with a new Foley catheter in and no new orders. The note did not indicate the size of the Foley catheter inserted in the emergency room. Review of the hospital discharge instructions dated 10/17/21 revealed the resident was seen for a Foley catheter insertion, hematuria (blood in the urine) and a urinary tract infection. The resident received one dose of intravenous Rocephin (antibiotic) in the emergency room (ER) with no additional antibiotic orders upon discharge. The discharge instructions did not indicate the size of the Foley catheter inserted while in the ER. Review of the progress notes revealed no evidence of the resident's non-compliance related to the indwelling catheter laying on the floor in December 2021 or January 2022. On 01/18/22 at 2:00 P.M. observation of Resident #7 revealed the resident's catheter bag was lying directly on the resident's floor without a barrier noted. The resident's catheter bag was also not covered for privacy. Interview with the resident at the time of the observation revealed he did not want a privacy bag over the catheter as he wanted to monitor the urine in the drainage bag. When asked if his bag always laid on the floor without a barrier, the resident stated yes, this was his preference so he could monitor the catheter draining. On 01/20/22 at 9:30 A.M. observation of Resident #7 revealed he was resting quietly in bed with his eyes closed. The catheter bag continued to lay on the resident's floor without a barrier. On 01/20/22 at 10:05 A.M. interview with Director of Nursing (DON) #103 verified the resident's catheter order did not address a balloon size and the order was to contain a balloon size as nurses could not make the determination of catheter size or balloon size and must have a physician's order for a change in catheter and/or balloon size. The DON #103 verified the current order from August of 2021 should have been clarified and clarification should have been documented. On 01/20/22 at 11:05 A.M. observation of Resident #7 with DON #103 and DON #104 revealed the resident was laying in bed with the catheter bag laying directly on the floor. The resident gave permission for DON #104 and the surveyor to assess the size of the catheter and balloon currently inserted in the resident. A #18 french Foley catheter with a 10 cc balloon was in place and verified by DON #104. On 01/20/22 at 11:07 A.M. DON #103 verified the resident's catheter was laying directly on the floor without a barrier and the expectation would be for staff to utilize a barrier and not place the resident's catheter bag on the floor. DON #104 asked the resident if a barrier could be applied between the resident's catheter drainage bag and the floor to which the resident answered yes. DON #104 then placed a towel on the floor as a barrier. Review of the facility policy titled Use of Indwelling Urinary Catheters/Foley Catheters, dated 03/07/15 revealed for a resident with an indwelling catheter, use appropriate infection control practices regarding hand washing, catheter care, tubing and the collection bags. 2. Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, essential hypertension, chronic pain altered, type 2 diabetes, altered mental status and chronic atrial fibrillation. 365975 Page 10 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan, dated 01/07/21 revealed the resident was at risk for infection due to urinary tract infection 11/10/2021-abscess indwelling Foley catheter, loose stool Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-Resistant Enterococci (VRE) IV site-midline pulled 01/05/2022. Interventions included report signs and symptoms of infection and administer medication as ordered. Review of the significant change MDS 3.0 assessment, dated 12/17/21 revealed Resident #60 had had mild impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. The resident was assessed to require two persons assist with mobility, transfers and toileting. The resident had an indwelling catheter. She received antibiotics three days during the review period. Review of the care plan, dated 12/03/21 revealed the resident had alteration in elimination, diagnoses of diabetes mellitus, hypertension, diuretic therapy, dementia, bowel and bladder incontinence. Interventions included a Foley catheter, Foley catheter care every shift and as needed, secure Foley catheter tubing to prevent accidental dislodgement Foley bag in place. On 01/18/22 at 2:25 P.M. during an interview with Resident #60, the resident's Foley catheter bag was observed hanging under her wheelchair directly touching the floor. On 01/19/22 at 8:23 A.M. Resident # 60 was observed sitting in her wheelchair with her Foley catheter bag directly touching the floor. On 01/19/22 at 8:38 A.M. staff were observed wheeling Resident #60 in the hallway toward the main entrance. The resident's Foley catheter bag was observed dragging on the floor. On 01/19/22 at 8:39 A.M. interview with Activity Staff (AS) #124 confirmed Resident #60's Foley catheter bag was dragging on the floor. AS #124 revealed the resident had a doctor's appointment and she was trying to get her out and did notice the bag was being dragged on the floor. However, AS #124 revealed she did not know where to place the bag as she was not trained to provide direct care. Following the interview, AS #124 was observed to seek assistance from one of the nursing assistants. On 01/19/22 at 8:47 A.M. interview with State Tested Nursing Assistant (STNA) #155 confirmed the resident's Foley bag should not be dragging or touching the floor. STNA #155 then covered the Foley catheter bag and hung it underneath Resident #60's wheelchair where it wasn't touching or dragging on the floor. On 01/20/22 at 11:00 A.M. interview with a facility DON revealed the facility expectation on placing Foley Catheter bags was to keep them off the floor to prevent infection. The DON revealed there was a cover staff were required to put the Foley bag inside before securing it on the chair or bed. She further revealed the Foley catheter bag should always be off the ground. Review of the facility policy titled Use of Indwelling Urinary Catheters/Foley Catheters, dated 03/07/15 revealed for a resident with an indwelling catheter, use appropriate infection control practices regarding hand washing, catheter care, tubing and the collection bags. 365975 Page 11 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, review of nutritional formula information and interview the facility failed to provide the appropriate tube feeding to meet nutritional needs for one resident (Resident #475) and failed to timely address a significant weight loss for one resident (Resident #53). This affected two residents (#53 and #475) of four residents reviewed for nutrition. The facility identified four residents with feeding tubes and ten residents with unplanned significant weight changes. Residents Affected - Few Findings include: 1. Review of Resident #53's open medical record revealed diagnoses including Alzheimer's disease, anemia, and type 2 diabetes mellitus. A weight of 195 was recorded 11/05/21 and a weight of 184 pounds was recorded on 12/07/21. A dietary assessment narrative, dated 12/15/21 at 6:00 P.M. indicated Resident #53 had a significant weight loss of 5.6% of his body weight in one month. However, Resident #53 had a significant weight gain of 10.8% in six months. The weight loss occurred post COVID-19 as the resident became more mobile. The note indicated Resident #53 was eating well and Registered Diet Tech (DTR) #183 recommended changing whole milk on trays to 2% for less kilocalories. Goals included for Resident #53 to have no more unplanned significant weight change. On 12/17/21 at 1:45 P.M., Dietitian #200 documented she agreed with the current interventions and plan of care. The dietitian and diet tech would continue to monitor. On 01/12/22, a weight of 164 pounds was recorded and there was no evidence the weight loss had been addressed. On 01/19/22 at 2:04 P.M., DTR #201 was asked if she could provide any input into Resident #53's recorded weight loss from December 2021 to January 2022 as there was no evidence it had been addressed. DTR #201 stated she would have to review the record because the facility's normal diet tech was off work. On 01/19/22 at 3:30 P.M., DTR #201 indicated she was covering for DTR #183 who was off work. DTR #201 stated she had Resident #53 re-weighed on 01/19/22 and he weighed 166 pounds which was still a significant weight loss. The family and physician were notified at that time. DTR #201 stated either the diet tech or the dietitian put weights in the computer. Dependent upon the view they used, they may or may not have seen previous weights when the last weight was entered. DTR #201 stated the diet tech and/or dietitian had seven days to document on weight changes. DTR #201 stated she understood the concern of waiting an additional seven days to address a significant weight loss that was identified due to the risk of further weight loss without intervention. DTR #201 stated after reviewing Resident #53's record she started a house supplement. Review of a dietary note dated 01/19/22 at 2:23 P.M. revealed Diet Tech #201 documented a recommendation for 120 milliliters of house supplement twice a day and weekly weights for four weeks. On 01/20/22 at 10:53 A.M., DTR #201 revealed the facility did not have a policy regarding significant weight loss but used the Medical Nutrition Therapy Best Practices which indicated significant weight loss or trending insidious weight loss should be documented timely, within seven days. DTR #201 reported residents should be reweighed within 72 hours if a variance of two to three pounds was 365975 Page 12 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0692 identified and the diet tech should be notified. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #475's medical record revealed diagnoses including dysphagia (difficulty swallowing), gastrostomy status, protein-calorie malnutrition and Alzheimer's disease. On 01/04/22 an order was received for the resident to receive nothing by mouth (NPO). On 01/13/22 a physician's order was noted for the resident to receive the enteral tube feeding product, Nutren 2.0 at 55 milliliters per hour (ml//hr) via feeding tube. No significant weight changes were recorded over the previous six months for the resident. Residents Affected - Few On 01/18/22 at 12:23 P.M. Resident #475 was observed receiving Isosource 1.5 through a feeding tube via pump at a rate of 55 milliliters per hour (ml/hr). Additional observations at 1:34 P.M., 2:15 P.M., 3:08 P.M. and 4:44 P.M. revealed no change in the solution or rate. On 01/19/22 at 8:42 A.M. Resident #475 was observed receiving Novasource renal at 55 ml/hr. There was no date, time or initials of who initiated the bag of nutrition. On 01/19/22 at 8:50 A.M. Licensed Practical Nurse (LPN) #173 verified Resident #475 had Novasource renal running instead of Nutren 2.0 that was ordered. LPN #173 revealed the facility had an interchange paper for alternate products that could be used which had similar nutritional value. However, at this time LPN #173 stopped the tube feed until she had the opportunity to verify the Novasource renal was an appropriate interchange to Nutren 2.0. Review of the nutrition interchange information revealed one alternative was listed for Nutren 2.0. The alternative was TwoCal HN. Review of Nutren 2.0 nutritional information revealed it provided two calories per milliliter. Calorie distribution (percentage of calories) revealed protein was 17%, carbohydrate was 43% and fat was 40%. Review of Isosource 1.5 nutritional information revealed it provided 1.5 calories per milliliter. Caloric distribution was 19% protein, 45% carbohydrate and 36% fat. Review of Novasource renal nutritional information revealed it provided two calories per milliliter. The caloric distribution was 18% protein, 37% carbohydrate and 45% fat. On 01/19/22 at 9:28 A.M., DTR #201 verified the Isosource 1.5 was lower in calories than the ordered Nutren 2.0. The Novasource renal had less potassium and sodium but the same calories. The products were not an appropriate interchange for each other. 365975 Page 13 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

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 and interview the facility failed to ensure Resident #19's oxygen was delivered at the rate ordered and failed to notify the physician when the resident's rate of oxygen was increased. This affected one resident (#19) of two residents reviewed for respiratory care. Residents Affected - Few Findings include: Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type 2 diabetes, dysphagia, atherosclerotic heart disease of native coronary artery and Barrette's esophagus. Review of the care plan, dated 10/22/21 revealed Resident #19 required oxygen due to diagnoses of chronic obstructive pulmonary disease, pneumonia, tracheostomy, and respiratory failure . Interventions included administer oxygen as ordered, medication as ordered, monitor lung sounds as ordered, monitor oxygen saturation as ordered, respiratory assessment/monitoring (by nurse), observe for signs of dyspnea that was labored respirations, low oxygen saturation and use of accessory muscles. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/09/21 revealed Resident #19 had no impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to require two persons assist with transfers, mobility and toileting. Review of the MDS revealed resident was on oxygen, suctioning, mechanical ventilation and received tracheostomy care. Record review revealed Resident #19 was transferred to the hospital on [DATE] and diagnosed with pneumonia. The resident returned to the facility on [DATE]. re-admission orders included: ventilator settings: Tidal Volume (VT):400, mode: Synchronized Intermittent Mandatory Ventilation (SIMV), Rate:14, Positive end-expiratory pressure (PEEP):15, Pressure support ventilation (PSV):15 oxygen bleed in : four every shift related to acute and chronic respiratory failure with hypoxia. The 01/16/22 physician's orders included orders for respiratory therapy: respiratory system observation, monitoring, and data collection of current respiratory deficiencies or abnormalities of pulmonary function: (COPD)/Ventilator Status three times a day and notify physician as needed. The 01/16/22 physician's orders also included to check oxygen saturation every shift while on oxygen. On 01/18/22 at 5:50 P.M. Resident#19's ventilator was set 16 breaths per minute, 400 tidal volume, PEEP 15 and oxygen was set at seven liters per minute. Review of the nurse's progress note, dated 01/19/22, revealed Resident #19 was on the ventilator on SIMV 400, 16 breaths per minute, 5 peep, 15 pressure sensitivity with an eight liter bleed in and saturation was 95% with bilateral breath sound (BBS) decreased throughout. The note revealed the resident had been off the ventilator for meals, then returned back to the ventilator. While off the ventilator the resident's oxygen saturations were low 92-90%. The resident took scheduled breathing treatments and had laboratory testing done this A.M. with results pending. Ventilator checks every six hours and as needed every six hours for tracheostomy care. On 01/19/22 at 8:58 A.M. Resident #19 was observed off the ventilator and had oxygen to her tracheostomy. The resident revealed she switched back and forth between the ventilator and oxygen to the 365975 Page 14 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0695 tracheostomy. Level of Harm - Minimal harm or potential for actual harm On 01/19/22 at 9:04 A.M. Resident #19's oxygen was observed to be set at seven liters per minutes via tracheostomy mask with the ventilator off. Residents Affected - Few On 01/19/22 at 1:45 P.M. Resident #19 was observed to have oxygen set at eight liters per minutes via tracheostomy mask with the ventilator off. Review of the respiratory Ventilator Check Sheet revealed oxygen should be set at five liters. Review of the check sheet revealed the resident's oxygen was increased on 01/19/22 at 9:15 A.M. to eight liters and at 12:50 P.M. to 10 liters. Interview on 01/19/22 at 3:30 P.M. with Respiratory Therapy (RT) #189 verified Resident's #19 oxygen was set higher than five liters per minutes as ordered. RT #189 revealed the resident's oxygen saturation was low so she increased resident oxygen to eight liters. She confirmed there was no order for the resident's oxygen level to be increased. She said she thought they had an order to increase resident's oxygen level, but verified there wasn't any order. 365975 Page 15 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

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. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure insulin and tuberculin solution were labeled appropriately after opening. This affected eight residents (#4, #479, #1, #22, #52, #175, #65 and #39 and had the potential to affect all 77 residents residing in the facility. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/05/20 with diagnosis of diabetes mellitus type two. Review of Resident #4's physician's orders revealed an order for Novolog insulin solution and Basaglar insulin solution for daily use. On 01/19/22 at 8:32 A.M. observation with Registered Nurse (RN) #177 revealed Resident #4's Novolog insulin solution and Basaglar solution were opened and had been used but did not include a date as to when they had been opened. Interview on 01/19/22 at 8:32 A.M. with RN #177 confirmed the medications were open, used and undated. 2. Review of Resident #479's medical record revealed an admission date of 01/15/22 with diagnosis of diabetes mellitus type two. Review of Resident #479's physician's orders revealed an order for a Humalog insulin pen. On 01/19/22 at 8:32 A.M. observation with RN #177 revealed Resident #479's Humalog insulin pen was opened, used and undated as to when it had been opened. Interview on 01/19/22 at 8:32 A.M. with RN #177 confirmed the medication was open, used and undated. 3. Review of Resident #1's medical record revealed an admission date of 10/27/16 with diagnosis of diabetes mellitus type two. Review of Resident #1's physician's orders revealed an order for Tresiba insulin pen. On 01/19/22 at 8:32 A.M. observation with RN #177 revealed Resident #1's Tresiba insulin pen was opened, used and undated as to when it had been opened. Interview on 01/19/22 at 8:32 A.M. with RN #177 confirmed the medication was open, used and undated. 4. Review of Resident #22's medical record revealed an admission date of 04/13/20 with diagnosis of diabetes mellitus. 365975 Page 16 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0761 Level of Harm - Minimal harm or potential for actual harm Review of Resident #22's physician's orders revealed orders for Novolog insulin solution and Tresiba insulin pen. On 01/19/22 at 8:32 A.M. observation with RN #177 revealed Resident #22's Novolog insulin and Tresiba insulin pen were opened, used and undated as to when they had been opened. Residents Affected - Some Interview on 01/19/22 at 8:32 A.M. with RN #177 confirmed the medication was open, used and undated. 5. Review of Resident #52's medical record revealed an admission date of 10/22/20 with diagnosis of diabetes mellitus. Review of Resident #52's physician's orders revealed orders for Humalog and Lantus insulin pens. On 01/19/22 at 8:48 A.M. observation with RN #175 revealed Resident #52's Humalog and Lantus insulin pens were opened, used and undated as to when they had been opened. Interview on 01/19/22 at 8:48 A.M. with RN #175 confirmed the medications were open, used and undated. 6. Review of Resident #175's medical record revealed an admission date of 01/15/22 with diagnosis of diabetes mellitus. Review of Resident #175 physician's orders revealed an order for a Humalog insulin pen. On 01/19/22 at 8:48 A.M. observation with RN #175 revealed Resident #175's Humalog insulin pen was opened, used and undated as to when it had been opened. Interview on 01/19/22 at 8:48 A.M. with RN #175 confirmed the medication was open, used and undated. 7. Review of Resident #65's medical record revealed an admission date of 01/18/21 with diagnosis of diabetes mellitus. Review of Resident #65's physician's orders revealed an order for Lantus insulin solution. On 01/19/22 at 8:48 A.M. observation with RN #175 revealed Resident #65's Lantus insulin pen was opened, used and undated as to when it had been opened. Interview on 01/19/22 at 8:48 A.M. with RN #175 confirmed the the medication was open, used and undated. 8. Review of Resident #39's medical record revealed an admission date of 03/16/21 with diagnosis of diabetes mellitus. Review of Resident #39's physician's orders revealed an order for Levemir insulin solution. On 01/19/22 at 8:48 A.M. observation with RN #175 revealed Resident #39's Levemir insulin solution was opened, used and undated as to when it had been opened. 365975 Page 17 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0761 Interview on 01/19/22 at 8:48 A.M. with RN #175 confirmed the medication was open, used and undated. Level of Harm - Minimal harm or potential for actual harm 9. Observation on 01/19/22 at 8:59 A.M. of the 100 hall medication room with RN #175 revealed a tuberculin purified protein derivative tubersol solution that was opened, used and undated as to when it had been opened. Residents Affected - Some Interview on 01/19/22 at 9:07 AM with RN #175 confirmed that the tuberculin solution was opened, used and undated. On 01/19/22 at 10:54 A.M. interview with Director of Nursing (DON) #103 revealed her expectation for staff would be to date insulin and tuberculin solutions when they were opened. DON #103 confirmed the insulin solutions for the residents identified above (#4, #479, #1, #22, #52, #175, #65 and #39) and tuberculin solution on the 100 hall medication cart were not labeled correctly. Review of the facility policy titled, Medication Administration, dated 06/21/17 revealed after multi-dose vials were initially used they were to be labeled with the date opened and initialed. Opened vials were to be discarded within 28 days of opening unless otherwise specified by the manufacturer. 365975 Page 18 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility guidance review and interview the facility failed to ensure laboratory testing for Resident #33 was obtained as ordered. This affected one resident (#33) of five residents reviewed for unnecessary medication use. Findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, major depressive disorder, dementia and Alzheimer's disease. Review of Resident #33's current physician's orders revealed an order for Seroquel 25 milligrams (antipsychotic) with directions to give half a tablet by mouth two times a day for dementia and an order (initiated 09/15/20) to obtain a fasting lipid panel annually in September due to the anti-psychotic medication use. Review of Resident #33's laboratory testing revealed Resident #33's last had a fasting lipid panel completed on 09/16/20. On 01/20/22 at 3:59 P.M. interview with Director of Nursing #103 confirmed Resident #33's fasting lipid panel was last done on 09/16/20 and it was missed for 2021. Review of the facility undated and untitled guidance for diagnostic and laboratory testing revealed the facility would provide or obtain, receive, review and communicate the results of diagnostic tests (laboratory and radiology) in accordance with the orders from a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with regulatory requirements. 365975 Page 19 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

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. Based on observation, review of an end of shift checklist, facility policy and procedure review and interview the facility failed to ensure food was stored and prepared under sanitary conditions to prevent contamination spoilage and/or food borne illness. This had the potential to affect 74 of 74 residents who received meal trays from the kitchen. The facility identified three residents (#58, #74 and #475) who received nothing by mouth. Findings include: On 01/19/22 beginning at 10:37 A.M. an initial tour of the kitchen with Dietary Supervisor #106 revealed the following concerns: A container of Barolta Pasta was opened, not sealed or dated when open. A container of Barolta elbow macaroni pasta was opened and not dated when opened. The walk-in freezer had beef burgers opened to air. The box was opened and the plastic bag the burgers were in was also opened and not sealed. A box of grilled chicken breast fillets was opened, the plastic bag was opened to the freezer air and not sealed. The reach in refrigerator had four rusty shelves. The reach in refrigerator had seals deteriorating on the bottom left and bottom right corners of the inside door frames. There were two individual servings of pureed cookies date 01/11/22. There were 18 single serve servings of beets dated 01/10/22. The scoop for the thickener was on the lid of the container. It was not contained in a scoop holder or bag. The ansul system above the cook top had dust on the piping over the curry chicken and rice soup and pot of pasta cooking below. The shelf above the cook top was dusty and grimy. There were two handled cups stored on the shelf. The metal back splash behind the cook top had dried yellow and white steams of liquid down it. The cook top and oven controls on the front of the cook top and oven had large amounts of dried debris caked on the controls. There was a bag of Klosteran wheat bread on a shelf under the toaster with a use by date of 01/03/22. The top of the convection oven was heavily dusty with a wet grimy grease look. 365975 Page 20 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the AM Aide end of shift check list and AM/PM [NAME] end of shift checklist revealed there were no cleaning sheets filled out from 01/01/22 through 01/09/22. There was only one AM/PM [NAME] end of shift checklist filled out for the month. Review of the facility Food Storage-Labeling and Dating policy, revised 07/2018 revealed leftovers were to be discarded after seven days. On 01/19/22 at 11:33 A.M. interview with Dietary Supervisor (DS) #106 verified there were opened food packages in the dry storage and freezer, undated opened packages and out dated leftovers and bread. DS #106 further verified the refrigerator had rusty shelves, the scoop for the thickener was not contained in a sanitary manner and the kitchen surfaces were not clean. Dietary Supervisor #106 verified dietary staff were not consistently completing the end of shift task documentation to ensure the kitchen area was being properly maintained. 365975 Page 21 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of Loeb Minimum Criteria for Initiating Antibiotic Therapy, review of the facility policy and procedure and interview the facility failed to ensure antibiotic use was appropriate to treat an infection for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #60's medical record revealed an admission date of 03/19/19 with diagnoses including acute kidney failure, diabetes and dementia. Review of the alteration in elimination due to diagnoses of diabetes, dementia, wound to buttocks and indwelling catheter plan of care initiated 03/26/19 revealed interventions included to monitor for signs and symptoms such as elevated temperature, dysuria (painful urination), flank pain, hematuria (blood in urine) and/or foul smelling urine, report to the physician and seek diagnosis and treatment promptly. Review of the resident was at risk for infection related to urinary tract infection plan of care initiated 04/08/21 revealed interventions included give antibiotic therapy as ordered, monitor for signs and symptoms of urinary tract infection (UTI) including foul smelling urine, cloudy urine, sediment and decreased urinary output; labs as ordered and inform the physician or nurse practitioner of abnormal labs. Review of the physician's orders, dated 12/10/21 revealed an order for a #16 french urinary catheter with a 30 milliliter balloon due to the resident having a wound vacuum. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 12/17/21 revealed the resident had moderate cognitive impairment and required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident had a urinary catheter and was frequently incontinent of bowel. Review of the progress notes dated 01/07/22 at 4:04 P.M. revealed the resident's catheter was draining thick, yellow urine. The nurse practitioner was notified and an antibiotic order was received. The resident and the resident's daughter were notified. The resident's catheter was also changed due to leaking. Review of the physician's order, dated 01/07/22 revealed an order for the antibiotic, Augmentin 875-125 milligrams one tablet by mouth two times a day for ten days due to a urinary tract infection. Review of the medication administration record (MAR) for January 2022 revealed Resident #60 received Augmentin from 01/08/22 through 01/17/22. Review of the January 2022 Infection Control Log revealed Resident #60 started on Augmentin for cloudy urine on 01/08/22 despite not meeting criteria for antibiotic use. A urinalysis was completed on 01/12/22 and contained less than 10,000 units of bacteria which was not generally considered significant. The medical record contained no evidence the physician was notified of the finding or the resident not meeting criteria for antibiotic use. 365975 Page 22 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Appendix 9 Loeb's Minimum Criteria for Initiating Antibiotic Therapy Flowsheet, dated 01/20/22 for Resident #60 revealed the minimum criteria for starting antibiotic therapy for a resident with a urinary catheter revealed at least one of the criteria needed to be present: rigors, new onset delirium, temperature greater than 100 degrees Fahrenheit or 2.4 degrees Fahrenheit above baseline and/or new costovertebral angle tenderness. Further review of the flow sheet revealed the resident did not meet criteria for the use of Augmentin. On 01/20/22 at 6:54 P.M. interview with Director of Nursing (DON) #103 verified the resident did not meet the facility's antibiotic use criteria with thick, yellow urine and the use of Augmentin was not warranted due to the resident's lack of symptoms. The DON verified additional criteria should have been met or the physician notified regarding the resident not meeting the criteria for antibiotic use. Review of the Antibiotic Stewardship Program Policy, dated 11/28/17 revealed it was the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse effects associated with antibiotic use. The Loeb Minimum Criteria were used to determine whether or not to treat an infection with antibiotics. 365975 Page 23 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident room repairs and issues were addressed timely after identification from staff. This affected 36 rooms of 52 rooms in the facility. The facility census was 77. Findings include: On 01/19/22 at 3:22 P.M. interview with Maintenance #184 revealed he did a walk through the facility and had identified areas of resident rooms including walls that needed repaired. Maintenance #184 revealed he had started on the North end of the facility but had only fixed one room as of this date. Review of the Room to Room Inspection Sheets, dated 11/17/21 revealed the following environmental issues were identified that needed repaired/addressed: room [ROOM NUMBER] needed painted behind bed. room [ROOM NUMBER] needed painting in the bathroom and the toilet was leaking. room [ROOM NUMBER] the door jams needed painted and minor touch up on the walls. room [ROOM NUMBER] the paint needed touched up behind bed B and the bathroom. The door jams need touched up. room [ROOM NUMBER] the wall needed patched and painted by the television and touched up in the bathroom. room [ROOM NUMBER] the wall needed patched and painted by the television and touched up in the bathroom. The door jams need touched up. room [ROOM NUMBER] needed painting in the bathroom and the door jams need touched up. room [ROOM NUMBER] the wall needed patched and painted by the clock and the door jams need touched up. room [ROOM NUMBER] required patching by the night stand and by Bed B and touch up door jams. room [ROOM NUMBER] the wall needed patched and painted by bed A and the door jams touched up. room [ROOM NUMBER] the wall needed patched and painted in the bathroom and door jams need touched up. room [ROOM NUMBER] needed paint on the alls in the bathroom and the door jams touched up. room [ROOM NUMBER] the door jams needed touched up. 365975 Page 24 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER] the wall needed patched and painted behind bed B and the door jams need touched up. room [ROOM NUMBER] The lower right wall in the bathroom needed painted. room [ROOM NUMBER] the wall needed painted and the bathroom patched and painted. The door jams needed touched up. room [ROOM NUMBER] the bathroom needed patched and painted and the door jams touched up. room [ROOM NUMBER] the right lower wall needed painted. room [ROOM NUMBER] the door jams needed touched up. room [ROOM NUMBER] the drywall by the corner of the bathroom needed repaired and the door jams needed touched up. room [ROOM NUMBER] the walls needed patched an painted and the door jams by the bathroom door needed painted. room [ROOM NUMBER] the walls needed patched and painted. room [ROOM NUMBER] the walls needed a touch up. room [ROOM NUMBER] the walls needed touched up in the bathroom. room [ROOM NUMBER] the ceiling had a crack in it. room [ROOM NUMBER] the walls needed patched and painted. room [ROOM NUMBER] the walls needed patched and painted. room [ROOM NUMBER] the walls needed touched up room [ROOM NUMBER] the walls in the bathroom needed touched up room [ROOM NUMBER] the walls needed touched up. room [ROOM NUMBER] the walls needed a touch up and there was a crack in the ceiling. room [ROOM NUMBER] the walls needed patched and painted. There was a crack in the ceiling. room [ROOM NUMBER] the walls needed patched and painted. room [ROOM NUMBER] the walls needed patched and painted in the bathroom. room [ROOM NUMBER] the walls needed touched up in the bathroom. room [ROOM NUMBER] the ceiling needed finish work. 365975 Page 25 of 26 365975 01/24/2022 Park Health Center 100 Pine Avenue St Clairsville, OH 43950

F 0921 Level of Harm - Minimal harm or potential for actual harm On 01/19/22 at 3:45 P.M. interview with Maintenance #184 revealed on 11/17/21 the maintenance men from two sister facilities went with him through the building and identified things that needed repaired. room [ROOM NUMBER] was the only room he had gotten to as he had been helping at a sister facility doing the maintenance. Maintenance #184 verified the paint and plaster damaged was noted over two months ago and only one room had been repaired as of this time. Residents Affected - Some 365975 Page 26 of 26