Health inspection·October 19, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and policy review, the facility failed to notify a resident representative when the resident had a change of condition. This affected one (#351) of two residents reviewed for notification of change. The facility census is 100. findings include: Medical record review for Resident #351 revealed an admission on [DATE] with diagnoses including but not limited to hypertensive heart and kidney disease with heart failure, stage four kidney disease, congestive heart failure, urinary retention, obstructive and reflux uropathy and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #351 revealed the resident had intact cognition. Resident #351 required moderate assistance from one staff member for bed mobility, transfers, and toileting. Review of the facility plan of care for Resident #351 revealed the resident is on hospice services and receiving end of life care. Interventions include: assess and treat pain as indicated, elevate head of bed (HOB) to facilitate breathing, medications as ordered and notify physician and responsible party of declines in condition. Review of the physician's orders for Resident #351 for the month of October 2023 revealed an order dated 10/16/23 for Keflex oral capsule 250 milligrams (mg) give 250 mg by mouth every 6 hours for cellulitis an order dated 10/16/23 for a venous Doppler ultrasound of the left arm to rule out deep vein thrombosis. Review of the facility's change of condition evaluation dated 10/16/23 at 4:40 A.M. revealed Resident #351 had pitting edema in bilateral upper extremities with increased warmth and redness. Urine in Foley catheter drainage bag was cloudy yellow with white casts. Further review of the evaluation revealed the hospice on call and the physician was notified, but not the resident representative. Review of the nurses progress note dated 10/15/23 at 10:30 P.M. revealed there was no notification to resident representative of the resident's change of condition. Review of the nurses progress notes dated 10/16/23 revealed there was no resident representative notification at the time of the evaluation and physician notification. Review of the nurse practitioner progress notes dated 10/19/23 at 11:42 A.M. Late Entry for Page 1 of 19 365984 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/16/23 revealed bedside visit was completed for new chief complaint of arms red with increased edema with a duration reported of one day. Assessment notes bilateral upper extremity with redness warmth and pitting edema that is firm. Resident #351 was diagnoses with cellulitis of bilateratal upper extremities Review of the nurses progress note dated 10/17/23 at 12:44 A.M. revealed new orders received for Keflex oral capsule 250 mg every six hours for five days, florastor daily for ten days and venous Doppler ultrasound of left arm. Resident #351 aware of new orders. Review of the nurses progress note dated 10/17/23 at 2:53 P.M. revealed Resident #351 was having increased anxiety, attempting to get out of bed without assistance and confusion. Hospice staff was notified and advised to give as needed oxycodone. Review of the nurses progress note dated 10/17/23 at 5:44 P.M. revealed the venous Doppler ultrasound was negative for blood clots. Interview on 10/19/23 at 11:20 A.M. with Assistant Director of Nursing (ADON) #525 verified Resident #351's representative was not notified of the residents change of condition. Review of the facility policy titled Change in a Resident's Condition or Status, dated 11/25/19, stated the facility shall promptly notify the resident, physician and representative of changes in the residents medical condition or status. 365984 Page 2 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and hospice staff interviews and review of the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment when a resident elected a different hospice agency. This affected one resident (#58) of two residents reviewed for hospice benefits. The facility census was 100. Findings include: Medical record review for Resident #58 revealed an admission on [DATE] with diagnoses including but not limited to ischemic heart disease, vascular dementia without behaviors, chronic obstructive pulmonary disease, diabetes mellitus with neuropathy, atrial fibrillation, chronic respiratory failure, morbid, hypertension, anxiety disorders, schizophrenia, pain and iron deficiency anemia. Review of quarterly MDS assessment dated [DATE] for Resident #58 revealed the resident had intact cognition. Resident #58 requires extensive assistance with two staff members for bed mobility and toileting, transfers did not occur during the assessment period, and eating was limited assist with one staff member. Resident #58 required total assistance with bathing by one staff member. Resident #58 was coded as receiving hospice benefits during the assessment period. Review of the plan of care for Resident #58 dated 06/30/22 revealed Resident #58 was receiving end of life care from hospice agency. Interventions include assess and treat pain as indicated/ordered, assess respiratory system as indicated, assist with ADL's as needed, collaborate care with hospice of resident/family/significant other's choosing. Review of the hospice agency's Initial Interdisciplinary Comprehensive Hospice Care Plan dated 06/30/22 revealed Resident #58 changed hospice providers and was admitted to the the new agency for hospice services. Review of the facility Electronic Health Record (EHR) MDS tab for Resident #58 revealed a significant change of condition was not completed within fourteen days of the change in hospice providers on 06/30/22. Interview on 10/18/23 at 12:24 P.M. with Hospice Registered Nurse (RN) #498 verified the start of care for Resident #58 was 06/30/22 from another hospice agency per resident request. Interview on 10/19/23 at 10:48 A.M. with MDS Registered Nurse (RN) #608 verified a comprehensive MDS was not completed when Resident #58 changed hospice providers, stating she was unaware of the requirement. Review of the Centers of Medicare and Medicare Resident Assessment Instrument (RAI) Manual version 3.0, chapter two, page 23 revealed a significant change MDS assessment should be completed within 14 days of an admission, if a resident changes hospice providers. 365984 Page 3 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to complete a resident-centered comprehensive care plan to address the use of antidepressant and antipsychotic medications. This affected one (#15) out of 25 residents reviewed for comprehensive care plans. The facility census was 100. Findings include: Review of the medical record for Resident #15 revealed an admission date of 06/20/19 with medical diagnoses of inflammatory polyarthropathy, Parkinson's disease, hypertension, psychotic disorder with delusions, adjustment disorder with anxiety, dementia, and Depression. Review of the medical record for Resident #15 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #15 moderate cognitive impairment and required moderate staff assist with toileting, bathing, dressing and transfers. The MDS indicated Resident #15 received an antipsychotic, antianxiety, antidepressant, and anticoagulant medication. Review of the medical record for Resident #15 revealed a physician order dated 10/31/21 for Nuplazid (antipsychotic medication) 34 milligram (mg) one tab by mouth daily for Parkinson's disease and an order dated 09/15/22 for Lexapro 20 mg one tab by mouth daily for anxiety. Review of the medical record for Resident #15 revealed no documentation to support a resident-centered comprehensive care plan was implemented for the use of antidepressant or antipsychotic medications including measurable goals and timeframe's to meet the residents medical, nursing, mental, and psychosocial needs. Interview on 10/19/23 at 9:44 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #15 did not contain a resident-centered comprehensive care plan to address the use of antidepressant and antipsychotic medication use which included measurable goals and timeframe's to meet the residents medical, nursing, mental, and psychosocial needs. Review of policy titled, Resident-Centered Care Plan, dated July 2022 stated a comprehensive resident-centered care plan will be developed and implemented for each resident, consistent with their resident rights, that includes measurable goals and timeframe's to meet the residents medical, nursing, mental and psychosocial needs, and will contain any services to be furnished to the resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being. 365984 Page 4 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

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 medical record review, observation, and staff interviews, the facility failed to follow physician orders regarding number of staff members ordered for the completion of activities of daily living (ADL'S). This affected one (#2) of two residents reviewed for ADL's for dependent residents. The facility census was 100. Residents Affected - Few Findings include: Medical record review for Resident #2 revealed an admission of 11/17/14 with diagnoses including but not limited to multiple sclerosis, psychotic disorder with hallucinations, neuromuscular dysfunction, bipolar disorder, major depressive disorder, low back pain, schizoaffective disorder, hypertension, anxiety disorder, obsessive compulsive disorder, diabetes mellitus, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed the resident had intact cognition. Resident #2 required total assist with two staff members for bed mobility, transfers, toileting. Resident #58 required extensive assist for eating. Resident #2 was incontinent of bowel and bladder. Review of the plan of care dated 11/18/14 for Resident #2 revealed the resident is dependent on staff for all ADL's related to weakness and limited mobility due to multiple sclerosis. Interventions include two person assist for all ADL's. Review of the physicians orders for the month of October 2023 for Resident #2 reveal an order dated 12/24/22 two person assistance for all ADL's. Observation on 10/17/23 at 3:37 P.M. of incontinent care with Agency State Tested Nursing Assistant (STNA) #499 revealed the staff member gathered supplies and placed them on the bedside table. STNA #499 explained to the resident what she was going to do and provided privacy. STNA #499 attempted to turn Resident #2 and the resident asked her if she was going to get some one else to help. STNA #499 explained that she was able to complete the task without assistance from another staff member. Resident #2 voiced concerns repeatedly and asked to be pulled up in bed so that he was able to hold the side rail. STNA #499 covered resident up and went into hallway to get another staff member. STNA #497 entered the room and pulled the resident up and then exited the room. STNA #499 turned the resident to expose perineal area and completed incontinent care independently. STNA #499 turned resident three times without the assist of a second staff member. Interview on 10/17/23 at 3:55 P.M. with STNA #499 verified incontinent care was completed without assistance from a second staff member. STNA #499 stated she received report from facility STNA and was not advised that Resident #499 required two assist for all ADL tasks. Interview on 10/17/23 at 4:01 P.M. with Registered Nurse (RN) #615 stated the facility has a sheet of paper that staff use to inform them of diet, transfers and how many staff it takes to complete the task. Surveyor requested to review the document and RN #615 attempted to retrieve the document from the nurses station desk drawer. RN #615 stated they were out of them right now and would have the Unit Supervisor print more. RN #615 provided a document from another hall and stated each resident was identified on the list and how the staff should care for them. Surveyor visualized document revealing resident's names, room numbers, diet, transfers instructions, incontinent status and individual needs of each resident. RN #615 verified Resident #2 should have two staff members assist with all 365984 Page 5 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0677 ADL according to physician orders. Level of Harm - Minimal harm or potential for actual harm Interview on 10/17/23 at 4:15 P.M. with Clinical Manager/LPN #616 stated the facility does not have to provide the surveyor with the document as it is not a part of the medical record. Residents Affected - Few Interview on 10/17/23 at 5:09 P.M. with STNA #499 stated she received a copy of the resident cheat sheet from the supervisor and was educated not to give the document to the surveyor. 365984 Page 6 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to assess and monitor a resident's bruising. This affected one (#56) of four residents reviewed for skin alterations. The census was 100. Residents Affected - Few Findings include: Review of Resident #56's medical record revealed an admission date of 04/26/21. Diagnoses listed included bone cancer, prostate cancer, type two diabetes mellitus, morbid obesity, asthma, heart failure, major depressive disorder, and anxiety. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was severely moderately impaired. Resident #56 was receiving Hospice services. Review of non-pressure injury assessments revealed no documentation of bruising to Resident #56's bilateral forearms. Review of treatment administration records (TAR's) for September 2023 and October 2023 revealed no documentation of any bruise monitoring for Resident #56's bilateral forearms bruises. Further review of Resident #56's medical record revealed there was no documentation regarding bruising. Observation of Resident #56 on 10/16/23 at 2:11 P.M. and on 10/18/23 at 2:16 P.M. revealed multiple bruises to his bilateral forearms. During an interview on 10/19/21 at 11:15 A.M. with Assisted Director of Nursing (ADON) #525 confirmed that Resident #56 had multiple bruises to bilateral arms. ADON #525 confirmed Resident #525 bruises were not documented as being assessed or monitored. Review of the facility's undated policy titled Wound and Skin Management Guidelines revealed a bruise will be either identified either on admission or in-house. An initial assessment of each bruise will be completed on Non-pressure use-defined assessments (UDA) in the electronic health record. An order will be obtained to monitor the bruise every shift until resolved and document in the electronic TAR. Any abnormalities will be monitored in the medical record. 365984 Page 7 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review, the facility failed to apply a residents restorative devices as ordered. This affected one (#58) of two residents reviewed for restorative devices. The facility census was 100. Findings include: Medical record review for Resident #58 revealed an admission on [DATE] with diagnoses including but not limited to ischemic heart disease, vascular dementia without behaviors, chronic obstructive pulmonary disease, diabetes mellitus with neuropathy, atrial fibrillation, chronic respiratory failure, schizophrenia, pain and iron deficiency anemia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #58 revealed the resident had intact cognition. No behaviors were coded for Resident #58. Resident #58 requires extensive assistance with two staff members for bed mobility and toileting, transfers did not occur during the assessment period, and eating was limited assist with one staff member. Review of the plan of care for Resident #58 dated 09/24/21 with revisions on 02/10/22 revealed the resident required activities of daily living (ADL's) assistance related to weakness. Interventions include one on one assistance for all meals; splint: apply SoftPro splint to right hand from 7:00 P.M. to 6:00 A.M. and for two hours between 9:00 A.M. and 12:00 P.M., and 2:00 P.M. to 5:00 P.M. as tolerated for improve positioning of hand. Please wash and dry hand and provide gentle range of motion to right hand/finger prior to application and after removal and utilize edema glove to right hand at all times. Remove for hygiene and skin checks. Keep right upper extremity elevated when in bed. Additionally the plan of care revealed staff to utilize edema glove to right hand at all times. Remove for hygiene and skin checks and keep right upper extremity elevated when in bed. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] for Resident #58 revealed custom palm protector was recommended. Review of the active physician orders for the month of October 2023 for Resident #58 revealed an order dated 08/27/23 for staff to please use fabricated palm protector (yellow heelbo with blue straps) to right hand at all times except for hygiene and range of motion (ROM). Please wash and dry hand and provide gentle ROM to right hand and fingers prior to application and after removal. Please assess for pressure areas, numbness, swelling, skin irritation, or pain. Contact therapy department if have questions or concerns. Observation on 10/18/23 at 11:34 A.M. of Resident #58 revealed the splint to right hand and edema glove was not in place Interview on 10/18/23 at 11:36 A.M. with State Tested Nursing Assistant (STNA) #645 verified that she did not put the splint on Resident #58 today and was unable to locate the splint in her room. Interview on 10/18/23 at 11:41 A.M. with Licensed Practical Nurse (LPN) #531 verified Resident #58 did not have a splint or a glove on per plan of care and physician orders. LPN #531 further verified Resident #58 had a foul odor coming from her right contracture hand and would have staff wash it 365984 Page 8 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0688 right away. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Restorative Program undated stated follow directions regarding the application of the splint/brace, prior to applying inspect for cleanliness and working order, apply brace as instructed in the plan of care. Residents Affected - Few 365984 Page 9 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #2 revealed and admission on [DATE] with diagnoses including but not limited to multiple sclerosis, psychotic disorder with hallucinations, neuromuscular dysfunction, bipolar disorder, major depressive disorder, low back pain, schizoaffective disorder, hypertension, anxiety disorder, obsessive compulsive disorder, diabetes mellitus, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed the resident had intact cognition. Resident #2 required total assist with two staff members for bed mobility, transfers, and toileting. Review of the plan of care for Resident #2 revealed resident was at risk for falls, impaired mobility related to weakness related to multiple sclerosis. Interventions include bed in low locked position, fall mat to left side of bed, two person assist for all activities of daily living, and call light within reach. Observation on 10/18/23 at 10:35 A.M. of Resident #2 revealed resident in bed watching television. Further observations revealed there was not a fall mat in place as ordered for Resident #2. Interview on 10/18/23 at 10:41 A.M. with Licensed Practical Nurse (LPN) #531 verified the bed was not in the lowest position and the fall mat was not in place and should have been. Observation on 10/18/23 at 2:19 P.M. of Resident #2 revealed resident in bed with eyes closed. Observations revealed there was no fall mat in place on the left side of Resident #2's bed. Interview on 10/18/23 at 2:23 P.M. with LPN #531 verified the fall mat was not in place and should have been. Review of the facility policy titled Managing fall and Fall Risk undated, stated based on assessments, previous evaluations and current data the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling. Based on medical record review, observations, staff interview, and policy review, the facility failed to ensure the ensure water temperatures in rooms were below 120 degrees Fahrenheit (F). This had the potential to affect 16 (#61, #28, #62, #201, #56, #16, #72, #35, #43, #15, #34, #68, #69, #29, #27 and #64) residents who were observed with high hot water temperatures in their rooms. Additionally, the facility also failed to implement fall precautions for a resident. This affected one (#2), out of two reviewed for falls. The facility census was 100. Findings include: 1. Observations of water temperature checks completed by Maintenance Director (MD) #533 on 10/16/23 from 11:54 A.M. through 3:48 P.M. revealed the following water temperatures that were greater than 120 degrees Fahrenheit (F): Resident #61's room water from bathroom faucet was 138.0 degrees F; Resident #28's room hot water from bathroom faucet was 132.0 degrees F; Resident #62 and #201's room hot water from bathroom faucet was 128.0 degrees F; Resident #56's room hot water from bathroom faucet was 126.0 degrees F; Resident #16 and #72's room hot water from bathroom faucet was 129.0 degrees F; 365984 Page 10 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #35 and #43's room hot water from bathroom faucet was 122.0 degrees F; Resident #15 and #34's room hot water from bathroom faucet was 134.3 degrees F; Resident #68 and #69's room hot water from bathroom faucet was 134.4 degrees F; Resident #29's room hot water from bathroom faucet was 121.0 degrees F; and Resident #27 and #64's room hot water from bathroom faucet was 123.0 degrees F. Interview on 10/16/23 12:23 P.M. with Maintenance Director #533 revealed he was not aware of hot water temperatures being out of the control limits of 109 to 120. Maintenance Director #533 also confirmed the water temperatures for Resident #61, #28, #62, #201, #56, #16, #72, #35, #43, #15, #34, #68, #69, #29, #27 and #64's rooms were above 120 degrees F. Review of facility policy Water Management Protocol dated April 2022 revealed the facility will maintain potable water hot water temperatures between 109 to 120 degrees F. 365984 Page 11 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was free from unnecessary psychotropic medication usage when the facility failed to monitor labs to ensure medication levels were therapeutic. This affected one (#80) out of five residents reviewed for unnecessary medication. The facility census was 100. Findings included: Review of the clinical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, asthma, acute and chronic respiratory failure with hypoxia, type II diabetes, schizoaffective disorder, major depressive disorder, hyperlipidemia, anemia, bleeding, gastro-esophageal reflux disease, and dependence on supplemental oxygen. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #80 revealed she had a Brief Interview for Mental Status (BIMS) score of 14. Resident #80 needed setup or clean-up assistance for eating, oral hygiene, toileting hygiene, and walking 10 or 50 feet. Resident #80 needed partial/moderate assist for showering or bathing herself and personal hygiene bipolar disorder, osteoarthritis, dysphagia, generalized anxiety disorder, hearing loss, acne vulgaris, postmenopausal . Review of the physician orders revealed she had an order for Depakote Sprinkles 125 milligrams (mg) give two capsules twice daily related to schizoaffective disorder. Resident #80 also had an order for a Depakote level in June and December. Review of Resident #80's medical record revealed a Depakote level was taken on 12/07/22. There was no other Depakote levels in Resident #80's medical record. An interview was conducted with the Director of Nursing (DON) on 10/19/23 at 9:20 A.M. revealed the facility provided a Depakote level dated 12/07/22. The DON was not aware of any Depakote levels obtained since then. 365984 Page 12 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and policy review, the facility failed to ensure meal tray delivery was done in a hygienic manner. This affected five (#12, #56, #201, #202 and #207) out of 11 residents observed on the D-Hall for meal service. The facility census was 100. Findings include: Observation of meal tray delivery on 10/18/23 from 11:54 A.M. through 12:04 A.M. revealed the following concerns: • State Tested Nursing Assistant (STNA) #524 pulled the tray for Resident #201 and entered the room without washing or sanitizing hands prior to entering the room. Upon exiting the room, STNA #524 did not wash her hands or use hand sanitizer. • STNA #524 pulled the tray for Resident #56 and entered the room without washing her hands or using hand sanitizer. While in the room, STNA #524 opened Resident #56 utensils and cut up the resident's food. STNA #524 exited the room without washing her hands or using hand sanitizer. • STNA #524 pulled the tray for Resident #12. STNA #524 took Resident #12's tray to the kitchen due to food plate needed updated. STNA #524 did not wash her hand or use hand sanitizer. • STNA #524 took the meal tray to Resident #20 and entered the room without washing her hands or using hand sanitizer. STNA #524 exited the room without washing her hands or using hand sanitizer. • STNA #524 pulled meal tray for Resident #202. STNA #524 entered Resident #202's room with the meal tray without washing her hands or using hand sanitizer. While in the room, STNA #524 opened the resident's utensils and assisted with set up for the resident. STNA #524 exited the room without washing her hands or using hand sanitizer. Interview on 10/18/23 12:06 PM with STNA #524 revealed she confirmed she did not wash her hands or use hand sanitizer between residents during meal tray pass. Interview with STNA #524 also confirmed she should wash her hand or use hand sanitizer between each resident during meal tray pass. STNA #524 also acknowledged soap and water or hand sanitizer was available in each room that she passed a meal tray to. Review of Hand Washing/Hand Hygiene Policy dated February 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Further review of the policy 365984 Page 13 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0812 revealed employees must was their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water before and after assisting a resident with meals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365984 Page 14 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident, staff and hospice staff interviews and policy review, the facility failed to collaborate with hospice in the development of a resident's comprehensive plan of care. This affected one (#58) of two reviewed for hospice services. The facility census was 100. Findings include: Medical record review for Resident #58 revealed an admission on [DATE] with diagnoses including but not limited to ischemic heart disease, vascular dementia without behaviors, chronic obstructive pulmonary disease, diabetes mellitus with neuropathy, atrial fibrillation, chronic respiratory failure, major depressive disorder, morbid, hypertension, anxiety disorders, insomnia, schizophrenia, pain and iron deficiency anemia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #58 revealed the resident had intact cognition. Resident #58 requires extensive assistance with two staff members for bed mobility and toileting, transfers did not occur during the assessment period, and eating was limited assist with one staff member. Resident #58 required total assistance with bathing by one staff member. Resident #58 was coded as receiving hospice services during the assessment period. Review of the facility plan of care for Resident #58 dated 06/30/22 revealed the resident was receiving end of life care for diagnoses of cerebral atherosclerosis. Interventions included assess and treat pain as ordered, assess cardiovascular status as indicated, assess fall risk and implement interventions, assess respiratory system as indicated, assist with activities of daily living as needed and collaborate care with hospice. Review of the hospice plan of care for Resident #58 dated 06/30/22 revealed the resident would be receiving the following services: nurse visit one time a week, social worker one time a month, chaplain visit one time a month and hospice aide one time a week. Hospice plan of care further stated nursing would monitor and evaluate symptoms, assist with pain management, social worker would provide emotional support, financial needs and interpersonal support and advance directive assistance. Review of the hospice long term care coordinated task plan of care undated for Resident #58 revealed hospice aide visits were scheduled on Monday and Thursday. Hospice nurse visits were scheduled on Thursdays. Review of the facility shower schedule for Resident #58 dated 08/21/23 revealed Resident #58 was scheduled for baths or showers on Friday 6:00 A.M. to 6:00 P.M. Review of the shower record in the electronic health record for Resident #58 revealed bathing/showers were provided by hospice. Further review of the document revealed the facility staff documented shower bed bath was completed on 09/19/23 (Tuesday), 09/21/23 (Thursday), 09/26/23 (Tuesday), 09/28/23 (Thursday), 10/03/23 (Tuesday), 10/05/23 (Thursday), 10/10/23 (Tuesday), 10/12/23 (Thursday), 10/16/23 (Monday), 10/17/23 (Tuesday). Review of the last document nurse visit for Resident #58 dated 09/27/23 (Wednesday) revealed vital signs were obtained, weight was documented at 161 pounds, code status was do not resuscitate comfort 365984 Page 15 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0849 care and hospice staff spoke with LPN at the facility. Level of Harm - Minimal harm or potential for actual harm Review of the hospice binder and skin issue notification sheet dated 10/16/23 (Monday) revealed the resident refused to have her hair washed. Further review of aide visits in the hospice binder revealed visits made on the following dates: 08/02/23 (Wednesday), 08/09/23 (Wednesday), 08/21/23 (Monday), 08/23/23 (Wednesday), 08/28/23 (Monday), 09/11/23 (Wednesday), 09/18/23 (Wednesday), 09/23/23 (Saturday), 10/02/23 (Monday)and 10/09/23 (Monday). Residents Affected - Few Observation on 10/16/23 at 1:43 P.M. of Resident #58 revealed resident in bed with eyes closed. Interview on 10/16/23 at 1:45 P.M. with Resident #58 complained about pain in her right hand. Resident #58 held up right hand to reveal third and forth digits were contracted. Noted foul smell on hand and resident reported the inability to extend fingers. Hospice Aide knocked and entered the resident's room and stated she was there to provide services. Interview on 10/18/23 via telephone at 12:24 P.M. with Hospice Registered Nurse (RN) #498 verified there was not a meeting with the facility to collaborate services. RN #498 verified she did not know what was on the facility plan of care regarding hospice services. RN #498 further stated staff member from marketing sends the facility notification that a meeting has been established. RN #498 stated hospice staff tries to keep the same schedule and they fax it to her, she is not sure where the schedule for the hospice visits are located at the facility. RN #498 was unaware of residents splint or orders for splint applications. Interview on 10/18/23 at 12:39 P.M. with State Tested Nursing Assistant (STNA) #715, assigned to the hall where Resident #58 resides stated she does not know where the schedule of visits for the hospice aide is posted. STNA #715 further stated she did not know when hospice was scheduled to visit but works all over the building and just knows who has hospice and when they come in. When asked specifically, STNA #715 stated that hospice comes on Tuesday and Thursday but is not sure. STNA #715 stated sometimes they write it on the board in the resident rooms, information location is different for all the residents. Interview on 10/18/23 at 12:43 P.M. with STNA #582 states she is not aware of any hospice schedule and knows that the hospice aide for Resident #58 comes in on Wednesdays. Interview on 10/18/23 at 2:19 P.M. with Licensed Practical Nurse (LPN) #531 assigned to Resident #58 stated she was unaware of the hospice schedule for the resident. Interview on 10/19/23 at 10:48 A.M. with the MDS Registered Nurse (RN) #608 verified she did not complete a comprehensive plan of care involving the hospice staff and facility staff when Resident #58 switched the hospice companies. Interview on 10/10/23 at 2:00 P.M. with Clinical Manager/LPN #616 verified the facility plan of care did not include chaplain visits, social worker visits, specific days or number of hospice aide visits, or specified care to be provided by each service provider. Review of the facility policy titled Hospice Referrals dated 07/24/18 stated develop and implement in conjunction with the hospice program a coordinated plan of care. 365984 Page 16 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, the facility failed to ensure enhanced barrier precautions were implemented as ordered. This affected two (#20 and #302) out of 24 residents reviewed for infection control. Additionally, the facility also failed to follow infection control practices during incontinence care. This affected one (#2) out of three residents reviewed for urinary tract infections and urinary catheters. The facility census was 100. Residents Affected - Few Findings included: 1. Record review revealed Resident #20 was admitted to the facility on [DATE]. His diagnoses included quadriplegia, pressure ulcer stage IV of the right buttock, paroxysmal atrial fibrillation, hyperlipidemia, anxiety disorder, noninfective gastroenteritis and colitis, gastro-esophageal reflux disease, autonomic dysreflexia, presence of a cardiac pacemaker, neuromuscular dysfunction of the bladder, vitiligo, age-related osteoporosis, constipation, insomnia, lactose intolerance, dysphagia, hypotension, presence of urogenital implants, chronic pain syndrome, and elevated blood-pressure reading without diagnosis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15. He needed extensive assist of one staff for bed mobility, dressing and toilet use. He was totally dependent on two staff for transfer. He needed supervision with setup help for locomotion and eating. He required limited assist of one staff for personal hygiene. He was totally dependent on one staff for bathing. He had a stage IV pressure ulcer which was present on admission. He had an indwelling urinary catheter. Review of the physician orders revealed Resident #20 had an order for Enhanced Barrier Precautions dated 05/22/23. 2. Record review revealed Resident #302 was admitted on [DATE]. His diagnoses included type II diabetes with foot ulcer, diabetic neuropathy, pressure ulcer unspecified stage, heart failure, chronic obstructive pulmonary disease, anxiety disorder, atherosclerotic heart disease of the native coronary artery, hyperlipidemia, seizures, ileus, gastro-esophageal reflux disease, hypertensive heart disease with heart failure, hypokalemia, personal history of transient ischemic attack and cerebral infarction, and retention of urine. Review of a Resident #302's record revealed the comprehensive MDS assessment was still being completed. Review of the clinical record revealed he had a stage II pressure to the left buttocks, a stage IV pressure ulcer to his right buttocks lateral, and a stage II pressure ulcer to the right buttocks distal. Review of the physician orders revealed Resident #302 had an order for Enhanced Barrier Precautions every shift dated 10/12/23. An interview was conducted with the Director of Nursing (DON) on 10/18/23 at 11:45 A.M. revealed the facility is placing all residents with a g-tube, Foley catheter, wound dressing and IV lines on enhanced barrier precautions. The DON revealed there will be an order and the personal protective equipment (PPE) will either be on a cart outside the door, or hanging inside the door. There should be a sign posted that the residents are on enhanced barrier precautions. 365984 Page 17 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation was made with Assistant Director of Nursing (ADON) #525 on 10/19/23 at 11:00 A.M. to 11:15 A.M. of Resident #20 and Resident #302's rooms. They each were observed to not have signage indicating they were on Enhanced Barrier Precautions or a supply of PPE. An interview was conducted with ADON #525 on 10/19/23 at approximately 11:15 A.M. revealed the rooms should have been set up for Enhanced Barrier Precautions if ordered. ADON #525 confirmed Resident #20 and #302 had orders for Enhanced Barrier Precautions. Review of the policy entitled Enhanced Barrier Precautions dated 10/21/22 revealed Enhanced Barrier Precautions required the use of gown and gloves only for high-contact resident care activities. It noted the precautions were recommended for residents known to be colonized or infected with a multi-drug resistant organism (MDRO) as well as those at increased risk of MDRO acquisition (for example residents with wounds or indwelling medical devices). 3. Medical record review for Resident #2 revealed and admission on [DATE] with diagnoses including but not limited to multiple sclerosis, psychotic disorder with hallucinations, neuromuscular dysfunction, bipolar disorder, major depressive disorder, low back pain, schizoaffective disorder, anxiety disorder insomnia, obsessive compulsive disorder, diabetes mellitus, and chronic pain. Review of the quarterly MDS assessment dated [DATE] for Resident #2 revealed intact cognition. Resident #2 required total assist with two staff members for bed mobility, transfers, toileting and extensive assist for eating. Resident #2 was incontinent of bladder and bowel. Review of the plan of care for Resident #2 dated 11/18/2014 revealed resident is dependent on staff for all activities of daily living (ADL). Resident #2 is incontinent of bowel and bladder. Interventions include two person assist for all ADL's, assist with ADL's as needed, document assistance as needed. Observation on 10/17/23 at 3:37 P.M. of incontinent care for Resident #2 revealed State Tested Nursing Assistant (STNA) #499 gathered supplies for task. STNA #499 placed clean towels, wash clothes, basin with water and perineal foam wash directly onto the over the bedside table without barrier. STNA #499 explained to the resident was she was going to do and provided privacy. STNA #499 moved the above stated supplies to the mattress on the bed without a barrier between them. STNA #499 prepared two clear plastic bags and set them on the floor beside the resident bed. STNA #499 completed Resident #2's perineal care without concerns. STNA #499 then placed the washcloths used to complete perineal care directly onto the bedside table without a barrier followed by the basin of water. STNA #499 removed the washcloths and placed them into the bags on the floor after assisting the resident to a comfortable position. STNA #499 emptied the water into the sink and removed the washcloths from the bedside table placing them into the clear bags on the floor. STNA #499 did not clean surface of bedside table before exiting the room. Interview on 10/17/23 at 4:00 P.M. with STNA #499 verified she did not have a barrier between the dirty washcloths or supplies when she placed them on Resident #2's bedside table and should have use a towel or placed them directly into the plastic bags. STNA #499 further verified she did not clean Resident #2's bedside table prior to exiting the room. Interview on 10/18/23 at 2:30 P.M. with Clinical Manager/Licensed Practical Nurse (LPN) #616 verified STNA #499 should not have placed the dirty wash clothes onto the bedside table and should have placed them directly into the plastic bags. 365984 Page 18 of 19 365984 10/19/2023 Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342

F 0880 Review of the facility policy titled Perineal Care, dated 02/12/2021 stated staff should clean the residents bedside stand during the procedure. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365984 Page 19 of 19