Health inspection·March 25, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were properly assessed for restraints. This affected one resident (#27) of two residents reviewed for restraints. The facility census was 57. Residents Affected - Few Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina, atrial fibrillation, dementia with behaviors, psychosis, anxiety disorder, major depression, and aphasia. Review of orders revealed no order for body pillows to bilateral bed or restraints. Review of a quarterly minimum data set (MDS) completed on 03/09/24 revealed Resident #27 did not have restraints. Review of assessments revealed no device assessment had been completed related to bilateral body pillows. Review of a care plan dated 03/19/24 revealed Resident #27 had an alteration in musculoskeletal status related to right wrist fracture with an intervention that included bilateral body pillows for comfort per resident request. Observation on 03/18/24 at 7:44 P.M. revealed Resident #27 was resting in a low bed, an assist rail to her right, and large bilateral body pillows. At the time of the observation, interview with State Tested Nursing Assistant (STNA) #113 revealed the body pillows were in place as a fall intervention for Resident #27. Observation on 03/20/24 at 11:36 A.M. revealed Resident #27 was resting in bed with bilateral body pillows in place. Observation on 03/21/24 at 8:48 A.M. revealed Resident #27 was laying diagonally in bed with her legs swung over the large body pillow to her right and trying to get out of bed. Interview on 03/21/24 at 8:58 A.M. with the Director of Rehab (DOR) #183 revealed Resident #27 was walking independently with a rollator prior to having a fall on 03/12/24. DOR #183 stated Resident #27 had been confused prior to fall but had been independent with transfers. DOR #183 stated she did not think Resident #27 was able to express her needs well. Page 1 of 31 366173 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/21/24 at 10:20 A.M. with Treatment Nurse (TN) #129 revealed prior to having a fall, Resident #27 was walking independently with a walker and transferring independently. TN #129 stated Resident #27 did not sustain injuries to her legs that would prevent her from walking but Resident #27 was using a wheelchair at this time for safety. TN #129 stated the bilateral body pillows were in place as a fall intervention and there should be a device evaluation for any type of device that restricts movement. TN #129 confirmed a device evaluation was not completed related to the bilateral body pillows. TN #129 confirmed Resident #27's care plan stated resident requested bilateral body pillows for comfort and stated Resident #27 had aphasia, so it is difficult for her to tell staff what she wants but it was possible for her to make her needs known. TN #129 acknowledged Resident #27 had a severely impaired cognition and typically a resident with that level of cognitive status was typically unable to make care decisions. Interview on 03/21/24 at 10:31 A.M. with MDS Nurse #200 revealed she had received an email from Director of Nursing (DON) stating Resident #27 had bilateral body pillows in place for comfort. MDS Nurse #200 confirmed the email from DON did not specify if the pillows were in place due to resident request. MDS Nurse #200 stated she was unsure why she added per patient request to the care plan. MDS Nurse #200 confirmed the MDS on 03/09/24 indicated Resident #27 was independent for transferring and walking. MDS Nurse #200 also confirmed a device evaluation was not completed regarding the bilateral body pillows. Interview on 03/21/24 at 10:57 A.M. with the DON revealed the bilateral body pillows were put in place for Resident #27's comfort due to a recent fracture. DON stated she will complete the device assessment and confirmed the bilateral body pillows were not in place at Resident #27's request. The DON confirmed Resident #27 was independent with transfers and walking prior to having a nasty fall where she hit her head. 366173 Page 2 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0641 Ensure each resident receives an accurate assessment. 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 interviews the facility failed to ensure assessments were accurate. This affected two residents (#21 and #26) of six reviewed for dental and one resident (#49) of two reviewed for discharges. The facility census was 57. Residents Affected - Few Findings included: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, anemia, benign paroxysmal vertigo, qualitative platelet defects. Review of the admission assessment dated [DATE] revealed the resident did not have her own teeth and had partial upper and lower dentures. Review of Resident #21's admission Minimal Data Set (MDS) dated [DATE] revealed the resident had no loose or broken full or partial dentures and was edentulous. The resident's brief interview for mental status (BIMS) score was 15 out of 15 (cognition intact). Review of Resident #21's dental note from the visiting dentist dated 12/04/23 revealed the resident was completely edentulous and the resident denied pain/discomfort and denied wanting new dentures. Review of dental noted from an out of facility dentist dated 12/13/23 revealed the resident needed a tooth extracted and a referral was recommended to affordable dentures for complete denture-maxillary, extract, erupted/exposed root, and mandibular partial-metal base with/sdls. Review of a general note dated 01/12/24 revealed the resident had some discomfort after having a tooth pulled on 01/11/24. Review of Resident #21's oral/dental plan of care revealed the resident had two different plans of cares. The first plan of care was dated 07/14/2023 revealed the resident has risk for oral/dental health problems r/t edentulous, wears upper and lower dentures. The second oral/dental plan of care was originally dated 08/14/23 revealed no evidence with the resident had oral or dental problems. The plan of care was updated on 11/16/23 to indicate it was related to fair dentation. On 02/15/24 it was updated to reflect related to the resident had her own natural teeth with upper dentures and lower partial. On 02/15/24 the related to was changed back to related to fair dentation, and finally on 03/13/24 it was changed back to related to the resident had her own natural teeth with upper dentures nd lower partial. Observation on 03/20/24 at 9:30 A.M., of Resident #21 with Registered Nurse (RN) #129 revealed the resident had a full upper denture and a bottom partial with five teeth on the partial and she had six natural teeth on the bottom. The resident reported she had a cavity in one tooth on the right side. The resident reported she needed new full upper dentures and a partial due to they were 20 plus years old. She currently wasn't having an issue with her dentures/partials or with the tooth with the decay, but she would like new dentures and partial. RN #129 confirmed the MDS was inaccurate, and the plan of care was not revised and there were two care plans. 366173 Page 3 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0641 Level of Harm - Minimal harm or potential for actual harm Interview on 03/19/24 at 1:20 P.M. with Resident #21 revealed she needed a new bottom partial and new full upper dentures. She had not followed up the dentist yet. Interview on 03/21/24 at 9:12 A.M., with the Director of Nursing (DON) confirmed the MDS was inaccurate, and the resident was not edentulous. Residents Affected - Few 2. Review of the medical record revealed Resident #49 was admitted on [DATE] and discharged on 11/07/23. Diagnoses included infection following surgical site and surgical aftercare. A nurse note dated 11/07/23 at 2:51 P.M. revealed Resident #49 was discharged to home. Review of Minimum Data Set (MDS) revealed a discharge MDS was not completed when Resident #49 was discharged home on [DATE]. Interview on 03/21/24 at 4:28 P.M. MDS #200 verified the discharge MDS for Resident #49 was not completed. 3. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including epilepsy, major depression, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of orders revealed Resident #26 had an order in place dated 10/16/21 to see audiologist, podiatrist, dentist, optometrist, and psychiatrist as needed. Review of a quarterly minimum data set (MDS) assessments dated 03/07/24 and 10/20/23 revealed Resident #26 had no difficulty chewing. Review of a care plan revised on 11/03/23 revealed Resident #26 had a care plan in place for being at risk for oral and dental health problems related to having her own natural teeth with some missing or broken, and reports of difficulty with chewing at times. Interventions included coordinate arrangements for dental care as needed or ordered. Interview on 03/19/24 at 9:30 A.M. with Resident #26 revealed the teeth she had left hurt. Interview on 03/20/24 at 5:26 P.M. with Regional Clinical Support (RCS) #200 confirmed the resident's dental care plan stated Resident #26 had difficulties chewing and the MDS' completed on 03/07/24 and 10/20/23 were not coded correctly for difficulty chewing. 366173 Page 4 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

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** 2. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, bipolar, post-traumatic stress disorder. Review of Resident #58's current plan of care revealed no evidence Resident #58 had a plan of care for anxiety disorder, depression, bipolar, post-traumatic stress disorder, behaviors, or refusal of care (showers). Observation on 03/18/24 at 8:00 P.M., revealed strong odors coming from Resident #58's room. Observation and interview on 03/19/24 at 9:30 A.M. with Resident #58, revealed Resident #58 had strong odors coming from his body. The resident voiced no concern regarding receiving assistance with activity of daily living care. The resident reported he needed to apologize to the two aides working last night because he read their body language wrong. The resident reported to the surveyor if he asked someone not to come in his room he means it. Interview on 03/21/24 at 9:46 A.M., with Regional Clinical Support (RCS) #199 revealed the resident had behaviors including refusing to shower. RCS #199 confirmed there was no care plan related to anxiety disorder, depression, bipolar, post-traumatic stress disorder including his target behaviors. Further review of Resident #58's plan of care dated 03/21/24 revealed the facility started to implement a plan of care for Resident #58's behaviors including a plan of care for post-traumatic stress disorder related to military services as evidence by the resident displays verbal aggression and was easily angered. 3. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, epilepsy, tracheostomy, gastrostomy, and bilateral foot drop. Review of provider notes dated 11/16/23 and 02/26/24 revealed Resident #48 had bilateral foot drop. Review of Resident #48's quarterly MDS dated [DATE] revealed the resident had upper extremity and lower extremity impairment on both sides. Review of Resident #48's functional abilities and goals assessment dated [DATE] revealed resident had upper extremity and lower extremity impairment on both sides. Review of hospice notes dated 11/15/23 indicated the resident had decrease range of motion (ROM), however no care plan or interventions noted for decreased ROM. Review of Resident #48's medical record revealed no documented evidence the resident was receiving ROM services. Review of Resident #48's current plan of care revealed no evidence of a plan of care for ROM or drop foot. 366173 Page 5 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/21/24 7:49 A.M. with RN #129 confirmed Resident #48 was not receiving restorative services due to the facility doesn't provide restorative services to hospice residents. Interview on 03/21/24 at 4:23 P.M. with Regional Clinical Support (RCS) #199 confirmed the facility or hospice had no plan of care for ROM, however she just spoke to the hospice nurse and the hospice reported she had implemented a ROM plan of care last week, but she has not brought the new plan of care to the facility and there was no documented evidence of the new ROM plan of care and it was not implemented. Based on record review and interview the facility failed to have care plans in place for Resident #1, #15, #48, and #58. This affected four residents (#1, #15, #48, and, #58) out of 21 residents. Facility census was 57. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included quadriplegia, epilepsy, and contracture of muscle-multiple sites. Review of Resident #1's plan of care revealed no evidence of a care plan for contracture's or restorative services. Range of motion assessment dated [DATE] revealed Resident #1 had full loss of voluntary movement to foot and ankle. The observation comments revealed Resident #1 had diagnoses of quadriplegia and range of motion was not inhibited, but Resident #1 was not able to move own extremities himself. The Functional abilities and goals assessment dated [DATE] revealed Resident #1 had functional limitations to both sides of upper extremity and lower extremity. Interview on 03/21/24 at 7:50 A.M. Registered Nurse (RN) #129 stated all residents were assessed quarterly for contracture's. RN #129 verified Resident #1 had diagnosis of multiple site contracture's, but did not have a plan of care in place for contracture's. 4. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anemia, and anxiety disorder. Review of a quarterly MDS completed on 02/14/24 revealed Resident #15 did not have mouth or facial pain or discomfort. Review of care plan revealed no oral or dental care plan had been completed. Interview on 03/19/24 at 10:03 A.M. with Resident #15 revealed she had not been offered a dentist appointment since admission to the facility and she had a tooth that bothers her. Interview on 03/20/24 at 5:18 P.M. with Regional Clinical Support #199 revealed the MDS nurse would complete the initial care plan, but then nursing and social services should add in their specific care plans. RCS #199 confirmed Resident #15 did not have a dental care plan. Interview on 03/21/24 at 8:41 A.M. with MDS Nurse #200 revealed if dental concerns are not triggered on the MDS, a dental care plan would not be completed. MDS Nurse #200 stated the activities of daily living care plan would indicate what level of assistance each resident should receive, but would not specify what type of oral care would be provided. 366173 Page 6 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, anemia, benign paroxysmal vertigo, qualitative platelet defects. Review of the admission assessment dated [DATE] revealed the resident did not have her own teeth and had partial upper and lower dentures. Review of Resident #21's admission Minimal Data Set (MDS) dated [DATE] revealed the resident had no loose or broken full or partial dentures and was edentulous. The resident's brief interview for mental status (BIMS) score was 15 out of 15 (cognition intact). Review of Resident #21's dental note from the visiting dentist dated 12/04/23 revealed the resident was completely edentulous and the resident denied pain/discomfort and denied wanting new dentures. Review of dental noted from an out of facility dentist dated 12/13/23 revealed the resident needed a tooth extracted and a referral was recommended to affordable dentures for complete denture-maxillary, extract, erupted/exposed root, and mandibular partial-metal base with/sdls. Review of a general note dated 01/12/24 revealed the resident had some discomfort after having a tooth pulled on 01/11/24. Review of Resident #21's oral/dental plan of care revealed the resident had two different plans of cares. The first plan of care was dated 07/14/23 revealed the resident has risk for oral/dental health problems r/t edentulous, wears upper and lower dentures. The second oral/dental plan of care was originally dated 08/14/23 revealed no evidence with the resident had oral or dental problems. The plan of care was updated on 11/16/23 to indicated it was related to fair dentation. On 02/15/24 it was updated to reflect related to the resident had her own natural teeth with upper dentures nd lower partial. On 02/15/24 the related to was changed back to related to fair dentation, and finally on 03/13/24 it was changed back to related to the resident had her own natural teeth with upper dentures nd lower partial. Observation on 03/20/24 at 9:30 A.M., of Resident #21 with Registered Nurse (RN) #129 revealed the resident had a full upper denture and a bottom partial with five teeth on the partial and she had six natural teeth on the bottom. The resident reported she had a cavity in one tooth on the right side. The resident reported she needed new full upper dentures and a partial due to the were 20 plus years old. She currently wasn't having an issue with her dentures/partials or with the tooth we the decay, but she would like new dentures and partial. Interview on 03/20/24 at 9:39 A.M., with RN #129 confirmed the MDS was inaccurate, and the plan of care was not revised to remove the plan of care dated 07/14/23 that indicated the resident was edentulous and wore upper and lower dentures. Review of Resident #21's quarterly MDS dated [DATE] revealed brief interview for mental status (BIMS) was 15 out of 15 (cognition intact). The resident as at risk for developing pressure 366173 Page 7 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0657 Level of Harm - Minimal harm or potential for actual harm ulcer/injuries. The resident had a pressure reducing device for bed, however there was no documented evidence the resident had pressure reducing device for chair. Review of Resident #21's skin/wound narrative note dated 03/08/24 revealed the resident had an area on her right buttocks that was open, and peri-wound was bright red but blanchable. Residents Affected - Few Review of Resident #21's non skin assessment dated [DATE] revealed the area Moisture Associated Skin Damage (MASD) and the area measured two cm by one cm by 0.2 cm. Area consistent with MASD, above treatment and toileting program initiated. Review of Resident #21's wound care note dated 03/13/24 revealed the Nurse Practitioner was asked to see the resident today for evaluation of wound to the right buttocks. Nursing staff reported the resident sits for prolonged periods of time throughout the day and doesn't reposition herself unless assisted by the staff. The resident has a Stage II pressure ulcer on the right buttocks that measured one centimeter (cm) by 0.2 cm by 0.1 cm. Review of Resident #21's pressure assessment dated [DATE] and completed on 03/18/24 revealed the area was first observed 03/08/24 and was in-house acquired. Risk factors included noncompliance with repositioning, urinary incontinence, and chronic prednisone treatment. The area measured one cm by 0.2 cm by 0.1 cm and was a Stage II pressure (partial-thickness skin loss with exposure dermis). The care plan was updated and revised. Review of a general note dated 03/14/24 revealed the resident was educated on sleeping in bed to help with pressure reduction. The resident reported she couldn't sleep well in bed and prefers the recliner. Review of Resident #21's right buttocks plan of care dated 03/08/24 revealed no evidence the area was pressure. The intervention included treat and supplements as ordered. There was no intervention for pressure relieving interventions. Review of Resident #21's plan of care for potential for impairment to skin integrity related to impaired mobility and incontinence dated 07/03/23 and revised 03/18/24 revealed the resident was noncompliant with lying in bed, prefers to lay/sleep in the recliner. There was no evidence the plan of care was revised to reflect the area was a Stage II pressure ulcer or evidence the interventions were revised to reflect a pressure relieving cushion in recliner/wheelchair. Observation of Resident #21 on 03/20/24 at 9:30 A.M. and 11:44 A.M. with RN #129 revealed the resident did not have a pressure relieving device in her recliner or wheelchair. The resident reported she had never had a pressure relieving device and the only thing she had was those green pads (incontinence/lift pads). The resident confirmed she doesn't sleep in bed and sleeps in her recliner at night. RN #129 reported the wound NP saw the resident today and changed the treatment to triad cream, however she has not documented the new orders yet or the measurement, however there was no change in the measurement of the pressure ulcer compared to last week's measurements. The RN confirmed the resident didn't have a pressure relieving pad in her wheelchair or recliner. The RN reported she verbally told staff on 03/08/24 to make sure they were moving the pressure relieving cushion device between the wheelchair and recliner. The RN reported the resident had a pressure relieving cushion prior to the development of the Stage II pressure ulcer as a preventative measure. The RN #129 reported staff usually share information on their report sheet when there were new recommendation/orders. The RN #129 confirmed she did not update the resident's right buttocks plan of care to reflect the area was 366173 Page 8 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a Stage II pressure due to on 03/08/24 she didn't think it was a pressure area and she did not update the plan of care to indicate the use of a pressure relieving device in wheelchair/recliner. 3. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses that included Alzheimer's, depression, occlusion and stenosis, anxiety disorder, and hemiplegia and hemiparesis. The quarterly Minimum Data Set, dated [DATE] revealed Resident #46 was cognitively impaired. Review of the electronic medical record revealed Interdisciplinary Care Conference Summary dated dated 05/05/23 at 6:08 P.M. for Resident #46. Resident #46, family, activities, dietary, nursing, and social worker attend the care conference. Interview on 03/21/24 at 9:09 A.M. Social Worker Designee #144 verified the last care conference recorded in the medical record for Resident #46 was on 05/05/23. Social Worker Designee #144 stated care conferences were held on 09/05/23 and 12/05/23 but were documented on paper instead of the electronic medical record. Interview on 03/21/24 at 11:06 A.M. family of Resident #46 verified they visited frequently and talked to staff but no formal care conferences had been held since May of 2023. Based on observation, record review and interview, the facility failed to ensure Residents #15, #26, and #46 had quarterly care conferences in conjunction with minimum data sets and failed to revise care plans for Residents #21. This affected four residents (#15, #21, #26, and #46). The facility census was 57. Findings included: 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anemia, and anxiety disorder. Review of minimum data set (MDS) list revealed Resident #15 had a quarterly MDS completed on 01/24/24. Review of assessments revealed Resident #15 had care conference meetings on 01/20/23, 05/02/23, 06/27/23, 09/29/23, and 03/05/24. There was no documentation of a care conference being completed between 09/29/23 and 03/05/24. Interview on 03/19/24 at 10:02 A.M. with Resident #15 revealed she had never been to a care conference. Interview on 03/20/24 at 3:25 P.M. with Social Worker Designee (SWD) #144 revealed care conference are offered quarterly and the schedules are determined by using an old MDS schedule that new residents are added to since there is no longer an MDS nurse in the building to communicate new schedules with her. SWD #144 confirmed a care conference should have been completed in January 2024 for Resident #15. 2. Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including epilepsy, major depression, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of MDS list revealed a quarterly MDS was completed on 03/07/24. Review of assessments revealed Resident #26 had care conferences completed on 02/24/24, 04/17/23, 07/17/23, and 10/25/23. Interview on 03/19/24 at 9:28 A.M. with Resident #26 revealed she was not invited to care planning 366173 Page 9 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0657 meetings. Level of Harm - Minimal harm or potential for actual harm Interview on 03/20/24 at 3:32 P.M. with SWD #144 confirmed Resident #26 was due for a care conference in January 2024 which was not completed. Residents Affected - Few Review of a policy titled Care Conference Guidelines dated 02/2022 revealed the facility should establish a routine schedule for care conferences with each resident at least quarterly and more often when necessary. A summary of the care conference should be documented in the medical record. 366173 Page 10 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

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 no medical record review, observation, and interview the facility failed to ensure residents who were dependent on staff received assistance with activities of daily living (ADL). This affected three residents (Resident #27, #37, and #165) of four reviewed for ADL. Residents Affected - Few Findings included: 1. Record review revealed Resident #165 was admitted to the facility on [DATE] with diagnoses including bronchitis, hypothyroidism, anemia, Parkinsonism, depression, gastro-esophageal reflux, and Alzheimer's. Review of Resident #165's general note dated 03/12/24 revealed the resident had all her own teeth. Review of Resident #165's functional abilities and goals dated 03/16/24 revealed the resident required some assistance (partial assistance from another to complete activities) for self-care needs. The resident was setup or clean-up assistance with oral hygiene. Review of Resident #165 oral/dental plan of care dated 03/13/24 revealed the resident had her own natural teeth. The intervention included coordinate arrangements for dental care, transportation as needed/as ordered. Dental consulted as needed. Monitor/document/report to nurse/doctor/family as needed for sign and symptoms of oral/dental problems needing attention. Observation and interview with Resident #165 on 03/19/24 at 10:20 A.M., revealed she hasn't had her teeth brushed since she had been admitted . The resident confirmed she had her own natural teeth. The resident reported her teeth felt gummy. There was no evidence dental supplies were available in the resident's room. Interview on 03/19/24 at 10:26 A.M. with State Tested Nurse's Aide (STNA) #190 confirmed the resident did not have oral/dental supplies in her room. STNA #190 reported she had looked earlier as well due to the resident had voiced concerns to her earlier. The STNA had brought the oral supplies into the resident's room at the time of the interview. 2. Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included Alzheimer's disease, emphysema, transient cerebral ischemic attack, and major depressive disorder. The annual Minimum Data Set, dated [DATE] revealed Resident #37 was cognitively intact. The bathing sheets dated 02/04/24, 02/07/24, 02/11/24, 02/14/24, 02/18/24, and 02/28/24 revealed Resident #37 was bathed and had fingernails trimmed and cleaned. Observation on 03/19/24 at 9:44 A.M. revealed Resident #37 had long finger nails. Interview on 03/20/24 at 12:11 P.M. Registered Nurse (RN) #129 verified Resident #37 had long fingernails with dark substance under some of the fingernails. RN #129 verified Resident #37's fingernails were too long to have been trimmed as indicated on the February (2024) bathing sheets. 366173 Page 11 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina, nondisplaced fracture of right ulna, atrial fibrillation, Colle's fracture of right radius, expressive language disorder, dementia with behaviors, and psychosis. Review of a quarterly minimum data set (MDS) assessment completed on 03/09/24 revealed Resident #27 required moderate assistance for oral hygiene, maximum assistance for toileting hygiene, maximum assistance for bathing, moderate assistance for dressing, maximum assistance for personal hygiene, and was frequently incontinent. Review of a care plan revised on 01/11/24 revealed Resident #27 had a self-care performance deficit related to dementia and impaired balance. Observation on 03/20/24 at 11:36 A.M. revealed Resident #27 had a clean pink shirt on and her hair was combed. Observation on 03/21/24 at 8:48 A.M. and 10:18 A.M. revealed Resident #27 was wearing the same clothes as the previous day. Interview on 03/21/24 at 10:45 A.M. with STNA #104 revealed she did not work the previous day and was unsure of what clothes Resident #27 had been wearing. STNA #104 stated she arrived for her shift at 6 A.M. and did help to feed breakfast but had not done check and changes yet for her shift. STNA #104 stated she was the only aide on the hallway but an aide from another hallway was currently in Resident #27's room checking on her. 366173 Page 12 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital record review, observation, and interview the facility failed to ensure wounds were properly identified as healed. This affected one resident (#23) of two residents reviewed for skin conditions. Facility census was 57. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included type 2 diabetes, Alzheimer's disease, and moderate protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had cognitive impairment and no skin concerns. A skin grid non-pressure form dated 01/10/24 at 11:53 A.M. revealed Resident #23 had a diabetic ulcer to the right foot planter surface below the fifth toe discovered on 01/10/24. The diabetic ulcer measured five centimeters (cm) long and two cm wide. The wound bed was covered with slough (yellow/white necrotic tissue). An order was received to paint the wound with betadine. A skin grid non-pressure form dated 02/07/24 at 10:45 A.M. reveled Resident #23 had a diabetic ulcer to right foot planter surface below the fifth toe that was resolved with a stable scab. No measurements of the scab were documented on the form. Review of hospital Discharge summary dated [DATE] revealed Resident #23 had an unstageable wound at the right fifth metatarsal base that was present upon admission on [DATE]. Santyl (enzymatic method of debridement to remove damaged skin to allow wound healing) covered with Allevyn (used for exudate absorption and management of partial to full thickness venous, arterial, diabetic, and pressure ulcers) was ordered. The treatment was to be completed daily until debridement occurred. Resident #23 was to follow up with the wound clinic. An admission head to toe assessment dated [DATE] at 3:15 P.M. revealed Resident #23 had calloused area to right fifth metatarsophangeal. No measurements were documented on the form. A skin grid non-pressure form dated 02/12/24 at 9:00 A.M. for Resident #23 revealed the right foot plantar surface below the fifth toe was first observed on 01/10/24. Resident #23 returned from the hospital with an order for Santyl to soften up the callous like area and for Resident #23 to follow up with the wound clinic. No measurements were documented on the form. A skin grid non-pressure form dated 02/21/24 at 8:48 A.M. for Resident #23 revealed the right foot plantar below the fifth toe was first observed on 01/10/24 and now measured 0.5 cm long and 0.2 cm wide, and 0.1 cm deep. A skin grid non-pressure form dated 03/06/24 at 11:12 A.M. for Resident #23 revealed the right foot plantar below fifth toe was first observed on 01/10/24 and was now healed. Interview on 03/21/24 at 2:59 P.M. Registered Nurse (RN) #129 verified the area to Resident #23 was healed while a scabbed area was still in place. 366173 Page 13 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 03/21/24 at 3:07 P.M. of the area to Resident #23's right foot plantar below the fifth toe revealed a circular white area with an open split area to the center of the wound. RN #129 verified Resident #23 had an open area to the center of the wound to the right foot plantar below the fifth toe. Interview on 03/21/24 at 3:14 P.M. Certified Nurse Practitioner (CNP) #201 verified the right foot plantar below the fifth toe was healed while a scab was still in place for Resident #23. Resident #23 was admitted to the hospital three days after the scabbed area was considered healed and the hospital identified the wound as a pressure ulcer. CNP #201 stated the area to Resident #23's foot was a callous and the hospital was incorrect in identifying the area as a pressure. CNP #201 stated the hospital debrided the area while Resident #23 was in the hospital which caused the area to reopen. CNP #201 verified they had healed the right foot plantar area below the fifth toe again on 03/06/24. CNP #201 was not aware of an open area to the right foot plantar area below the fifth toe. 366173 Page 14 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide Resident #15 with an optometry consult. This affected one resident (#15) of two residents reviewed for optometry services. The facility census was 57. Residents Affected - Few Findings included: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anemia, and anxiety disorder. Review of a quarterly Minimum Data Set, dated [DATE] revealed Resident #15 had moderately impaired vision. Review of care plan dated 02/02/24 revealed Resident #15 had moderately impaired vision and interventions included to arrange a consultation with eye care practitioner as required. Record review revealed no evidence of a visual consult consent form being completed for Resident #15. Review of 360Care vision lists from 03/06/23, 06/22/23, 08/02/23, and 09/28/23 revealed Resident #15 was not seen by the eye doctor. Interview on 03/19/24 at 10:06 A.M. with Resident #15 revealed she has a hard time seeing things far away and she had not seen an eye doctor since admission. Interview on 03/20/24 at 3:25 P.M. with Social Worker Designee (SWD) #144 revealed she thought a 360Care consent had been filled out for Resident #15 to see the eye doctor but was unable to locate it. SWD #144 confirmed Resident #15 was not on any of the vision lists from 360Care. SWD #144 stated she was unaware of Resident #15's new care plan for a visual consult. Interview on 03/20/24 at 5:18 P.M. with Regional Clinical Support #200 confirmed Resident #15 had a care plan for a visual consult on 02/02/24 and the MDS stated Resident #15 had moderately impaired vision. 366173 Page 15 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, interviews, and policy review the facility failed to ensure pressure relieving intervention were in-place. This affected one resident (#21) of three residents reviewed for pressure ulcers. The facility census was 57. Residents Affected - Few Finding included: Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, anemia, benign paroxysmal vertigo, qualitative platelet defects. Review of Resident #21's Braden Scale (predictor for pressure ulcers) dated 01/17/24 revealed not at risk for pressure. She had a potential problem for friction and shearing, mobility was slightly limited, walked occasionally, rarely moist. Review of Resident #21's quarterly MDS dated [DATE] revealed brief interview for mental status (BIMS) was 15 out of 15 (cognition intact). The resident was at risk for developing pressure ulcer/injuries. The resident had a pressure reducing device for bed, however there was no documented evidence the resident had pressure reducing device for chair. Review of Resident #21's skin/wound narrative note dated 03/08/24 revealed the resident had an area on her right buttocks that was open, and peri-wound was bright red but blanchable. Review of Resident #21's non skin assessment dated [DATE] revealed the area to the right buttocks was Moisture Associated Skin Damage (MASD) and the area measured two cm by one cm by 0.2 cm. Area consistent with MASD, above treatment and toileting program initiated. Review of Resident #21's wound care note dated 03/13/24 revealed the Nurse Practitioner was asked to see resident today for evaluation of wound to the right buttocks. Nursing staff reported the resident sits for prolonged periods of time throughout the day and doesn't reposition herself unless assisted by the staff. The resident has a Stage II pressure ulcer (partial-thickness skin loss with exposed dermis) on the right buttocks that measured one centimeter (cm) by 0.2 cm by 0.1 cm. Review of Resident #21's pressure assessment dated [DATE] and completed on 03/18/24 revealed the area was first observed 03/08/24 and was in- house acquired. Risk factors included noncompliance with repositioning, urinary incontinence, and chronic prednisone treatment. The area measured one cm by 0.2 cm by 0.1 cm and was a Stage II pressure (partial-thickness skin loss with exposure dermis). The care plan was updated and revised. Review of a general note dated 03/14/24 revealed the resident was educated on sleeping in bed to help with pressure reduction. The resident reported she couldn't sleep well in bed and prefers the recliner. Review of Resident #21's right buttocks plan of care dated 03/08/24 revealed no evidence the area was pressure. The intervention included treat and supplements as ordered. There was no intervention for pressure relieving interventions. 366173 Page 16 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0686 Level of Harm - Minimal harm or potential for actual harm Review of Resident #21's plan of care for potential for impairment to skin integrity related to impaired mobility and incontinence (dated 07/03/23 an revised 03/18/24) revealed the resident was noncompliant with lying in bed, prefers to lay/sleep in the recliner. There was no evidence the plan of care was revised to reflect the area was a Stage II pressure ulcer or evidence the interventions were revised to reflect a pressure relieving cushion in recliner/wheelchair. Residents Affected - Few Observation of Resident #21 on 03/20/24 at 9:30 A.M. and 11:44 A.M. with Registered Nurse (RN) #129 revealed the resident did not have a pressure relieving device in her recliner or wheelchair. The resident reported she had never had a pressure relieving device and the only thing she had was those green pads (incontinence/lift pads). The resident confirmed she doesn't sleep in bed and sleeps in her recliner at night. RN #129 reported the wound NP saw the resident today and changed the treatment to triad cream, however she has not documented the new orders yet or the measurement, however there was no change in the measurement of the pressure ulcer compared to last week's measurements. The RN confirmed the resident didn't have a pressure relieving pad in her wheelchair or recliner. RN #129 reported she verbally told staff on 03/08/24 to make sure they were moving the pressure relieving cushion device between the wheelchair and recliner. RN #129 reported the resident had a pressure relieving cushion prior to the development of the Stage II pressure ulcer as a preventative measure. RN #129 reported staff usually share information on their report sheet when there were new recommendation/orders. The RN confirmed she did not update the resident's right buttocks plan of care to reflect the area was a Stage II pressure due to on 03/08/24 she didn't think it was a pressure area and she did not update the plan of care to indicate the use of a pressure relieving device in wheelchair/recliner. Interview on 03/20/24 12:13 PM with RN #129 revealed she should have completed a new Braden assessment after the resident was identified with a new skin alteration, however she was off of work for a week after the area was identified. Review of facility policy and procedure titled Wound Management program (dated 11/2021) revealed Stage II pressure ulcer was partial-thickness skin loss with exposure dermis. Wound management principles provide the basis for effective wound care and are considered in development of the plan of care. Individualized care plan would be updated on ongoing basis. 366173 Page 17 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0687 Provide appropriate foot care. 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 interviews the facility failed to ensure foot care was provided for a resident. This affected one resident (#32) out of four reviewed for activities of daily living. Facility census was 57. Residents Affected - Few Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE] with diagnoses that included chronic embolism and thrombosis, celiac disease, protein-calorie malnutrition, and adult failure to thrive. The quarterly Minimum Data Set, dated [DATE] revealed Resident #32 had cognitive impairment and was dependent on staff for activities of daily living. A podiatry consent form was signed on 02/08/24. Observation on 03/19/24 at 8:09 A.M. revealed Resident #32 had long toenails with several toenails curling under the toes. Interview on 03/19/24 at 3:29 P.M. Registered Nurse (RN) #129 verified Resident #32 had long, jagged toenails. RN #129 also verified the toenails to the second and third toe on Resident #32's left foot were curling under the toes. Interview on 03/20/24 at 9:08 A.M. Social Worker Designee #144 verified Resident #32 had not seen a podiatrist since admission. 366173 Page 18 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

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** 2. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, epilepsy, tracheostomy, gastrostomy, and bilateral foot drop. Review of provider notes dated 11/16/23 and 02/26/24 revealed Resident #48 had bilateral foot drop. Review of Resident #48's quarterly MDS dated [DATE] revealed the resident had upper extremity and lower extremity impairment on both sides. Review of Resident #48's functional abilities and goals assessment dated [DATE] revealed the resident had upper extremity and lower extremity impairment on both sides. Review of hospice notes dated 11/15/23 indicated the resident had decrease range of motion (ROM), however no care plan or interventions noted for decreased ROM. Review of Resident #48's medical record revealed no documented evidence the resident was receiving ROM services. Review of Resident #48's current plan of care revealed no evidence of a plan of care for ROM or drop foot. Interview on 03/21/24 7:49 A.M. with RN #129 confirmed Resident #48 was not receiving restorative services due to the facility doesn't provide restorative services to hospice residents. Interview on 03/21/24 at 4:23 P.M. with Regional Clinical Support (RCS) #199 confirmed the facility and hospice had no plan of care for ROM for Resident #48, however she just spoke to the hospice nurse and the hospice reported she had implemented a ROM plan of care last week, but she has not brought the new plan of care to the facility and there was no documented evidence of the new ROM plan of care nor it was implemented. Based on record review and interview, the facility failed to provide range of motion services for residents. This affected two residents (#1, #48) of four residents reviewed for range of motion services. Facility census was 57. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included quadriplegia, epilepsy, and contracture of muscle-multiple sites. Range of motion assessment dated [DATE] revealed Resident #1 had full loss of voluntary movement to foot and ankle. The observation comments revealed Resident #1 had diagnosis of quadriplegia and range of motion was not inhibited, but Resident #1 was not able to move own extremities himself. The Functional abilities and goals assessment dated [DATE] revealed Resident #1 had functional limitations to both sides of upper extremity and lower extremity. 366173 Page 19 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0688 Level of Harm - Minimal harm or potential for actual harm Interview on 03/21/24 at 7:50 A.M. Registered Nurse (RN) #129 stated all residents were assessed quarterly for contracture's. RN #129 verified Resident #1 had diagnosis of multiple site contracture's, but did not have any range of motion services in place. Residents Affected - Few 366173 Page 20 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital record review, and interviews, the facility failed to ensure Resident #23 received adequate care for treatment of an urinary tract infection. This affected one resident (#23) of three residents reviewed for urinary tract infections. Facility census was 57. Actual harm occurred on 02/03/24 when Resident #23, who had a diagnosis of Alzheimer's disease and cognitive impairment, exhibited signs of an urinary tract infection including dark, cloudy urine without evidence of timely identification or treatment of the infection. On 02/07/24 at 10:45 P.M. (four days later) the resident was assessed to have an elevated temperature of 102.3 degrees Fahrenheit with altered mental status. The resident was transferred to the emergency room and subsequently admitted with a diagnosis of sepsis with acute metabolic encephalopathy due to acute urinary tract infection/acute pyelonephritis. The resident was hospitalized for three days. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, Alzheimer's disease, neuromuscular dysfunction of bladder, history of transient ischemic attack, and overactive bladder. An assessment/plan from urologist dated 01/24/24 revealed Resident #23 had benign prostatic hyperplasia that was managed with an indwelling catheter. Resident #23 also had bladder perforation. A new catheter was placed on 01/24/24. A general note dated 02/03/24 at 4:55 A.M. revealed a nursing assistant notified the nurse Resident #23 had dark cloudy urine. The note indicated Resident #23 would continue to be monitored. A general note dated 02/05/24 at 1:18 A.M. revealed a nursing assistant reported to the nursing staff Resident #23's urine continued to be dark and cloudy. Resident #23 was on the certified nurse practitioner list to be seen on rounds. A general note dated 02/05/24 at 5:57 A.M. (documented on 02/06/24 at 5:59 P.M.) revealed the nurse spoke with Resident #23's urologist office regarding Resident #23's urine results due to Resident #23 had traces of blood and thick orange/yellow urine. The urologist office stated they were trying to find Resident #23's results and would return the call when the results were found. A general note dated 02/06/24 at 12:59 P.M. revealed a message was left with Resident #23's urologist office regarding Resident #23's urine results. A general note dated 02/07/24 at 10:45 P.M. revealed the nurse entered Resident #23's room to perform evening nursing assessment. Resident #23 had a large bowel movement and appeared shaky. When Resident #23 was asked if he was okay, Resident #23 just looked at the nurse and did not say anything. The nursing assistant stated Resident #23 was not acting like his normal self. Resident #23's blood pressure was 118/67 mmHg, pulse was 124 beats per minute, oxygen saturation was 93% on room air, respirations were 24 breaths per minute, and temperature was 102.3 degrees Fahrenheit . A decision was made to send Resident #23 to the hospital for evaluation due to altered mental status and abnormal vitals. 366173 Page 21 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0690 Level of Harm - Actual harm Residents Affected - Few Review of the hospital Discharge summary dated [DATE] revealed Resident #23 was brought to the hospital on [DATE] with complaints of altered mental status and fever. The nursing home staff reported Resident #23 was more confused than dementia baseline. Resident #23 was admitted to the hospital with sepsis (the body's overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death) due to acute urinary tract infection/acute pyelonephritis (kidney infection). Resident #23 had acute metabolic encephalopathy (disturbance of brain function caused by a chemical imbalance in the blood) due to sepsis. Resident #23 was ordered Keflex (antibiotic) 250 milligram three times a day for 21 days. A general note dated 02/10/24 at 3:00 P.M. revealed Resident #23 returned to the facility in stable condition. Resident #23 had an indwelling catheter draining cloudy, yellow urine. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had cognitive impairment and an indwelling catheter. Interview on 03/21/24 at 2:52 P.M. Registered Nurse (RN) #129 revealed the urologist was the only one able to change Resident #23's indwelling catheter. RN #129 stated the urologist was contacted when the catheter could not be flushed. RN #129 stated she believed Resident #23 had the indwelling catheter in place for more than 14 days so a urine sample could not be obtained. Review of the documentation revealed the indwelling catheter was placed on 01/24/24. Resident #23 had dark cloudy urine ten days after catheter had been placed. RN #129 stated the facility had called the urologist to obtain the urinalysis results from the urologist during the 01/24/24 visit. Interview on 03/21/24 at 3:21 P.M. RN #400 revealed the RN worked for the urologist who saw Resident #23. The RN verified the urologist was the only one allowed to change the resident's catheter. RN #400 revealed if there were any changes or concerns, the facility could contact the urologist office. RN #400 revealed there was no evidence the facility had attempted to call the urologist regarding Resident #23. The urologist was notified by the hospital that Resident #23 was admitted with a urinary tract infection. RN #400 verified if the urologist office was closed and there were any concerns, Resident #23 could be sent to the hospital for evaluation. The urologist was on call at the hospital for patients who were seen in the emergency department. 366173 Page 22 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

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 medical record review, observation, interview, and policy review the facility failed to ensure Residents Affected - Few appropriate storage of resident nebulizer equipment. This affected one resident (#58) of one reviewed for respiratory care. Findings included: Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic obstructive pulmonary disease (COPD). Review of Resident #58's orders dated 02/12/24 revealed orders for Albuterol Sulfate Inhalation Nebulization Solution 1.25 milligram (mg)/3 milliliters (ml) inhale orally via nebulizer four times a day for shortness of breath. There was no evidence of orders on how frequently to change the tubing and mask. Review of Resident #58's COPD plan of care dated 02/16/24 revealed no evidence of storage or maintained of the nebulizer equipment. Observations on 03/19/24 at 9:34 A.M. of Resident #58's nebulizer equipment revealed the nebulizer mask was hanging off the dresser and not stored in a bag. Observation on 03/21/24 at 8:47 A.M., of Resident #58's nebulizer equipment with the Director of Nursing (DON) confirmed the resident nebulizer mask was lying on the resident dresser without a barrier and the nebulizer was filled with medication. The nebulizer was dated 02/18/24. The DON reported nebulizer equipment should be stored in a bag when not in use and there should have been an order to change the mask and tubing weekly. The DON disposed of the mask and tubing at the time of the observation. Interview on 03/21/24 at 10:08 A.M. with the DON confirmed the mask was not properly stored and should have been placed in a bag when not in use and there was no order to change the mask and tubing weekly. Review of the facility policy titled Aerosol Therapy (undated) revealed to disassemble nebulizer and shake any remaining medication from nebulizer. Place nebulizer, mouthpiece, or mask in a plastic set up bag. There was no evidence on how frequently to change the mask and tubing. 366173 Page 23 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic obstructive pulmonary disease, Residents Affected - Few Review of Resident#58's census revealed the resident was covered under Medicare from 12/18/23 until 02/29/24. Review of Resident #58's admission MDS dated [DATE] revealed the resident had his own natural teeth and there was no obvious or likely cavity or broken natural teeth. Review of admission assessment dated [DATE] and re-admission on [DATE] revealed the resident had his own teeth and no broken or carious teeth. Review of Resident #58's baseline care plan for ancillary services dated 12/18/23 revealed the goal was to provide necessary support in achieving ancillary needs. Review of Resident #58's oral/dental plan of care dated 12/20/23 revealed to coordinate arrangements for dental care, transportation as needed/as ordered. Review of Resident #58's paper and electronic medical record revealed no evidence the resident accepted or declined dental services. Review of dental visit list dated 03/11/24 and 12/04/23 revealed no evidence the resident was seen or referred to the dentist. Interview on 03/19/24 at 9:19 A.M., with Resident #58 revealed he had not seen a dentist since he had been admitted but he needs to see one. The residents' teeth appeared to discolored and poor condition. The resident had teeth missing on the bottom that were visible. The resident denied pain or discomfort. Interview on 03/20/24 at 2:13 P.M., with the Director of Nursing (DON) revealed she could not find dental consents or evidence the resident had been seen by a dentist. The DON reported the facility had acquired a new ancillary service company and it was their understanding that the company would obtain consents upon admission and arrange services. Interview on 03/20/24 at 2:41 P.M., with the Administrator and Social Worker (SW) #144 revealed it was the facility understanding the new ancillary company was going to get consents from the resident or representative and arrange appointments. The facility was not aware this was not being done. Review of the Ancillary Contract dated 07/15/23 revealed the duties and responsibilities of each facility was to obtain consent for medical and healthcare services either from the resident or from the resident's responsible party, which consent shall remain valid in and in force for the entire length of stay of the resident unless otherwise revoked by the resident or the responsible party. Review of the facility policy and procedure titled Resident Healthcare Appointments/Ancillary Services (dated 02/2022) revealed upon admission or shortly thereafter ancillary services such as dental would be offered, and consent accepted or declined. Periodically throughout the residents stay they 366173 Page 24 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few will be asked if given they consent for ancillary services. A resident may sign consent for ancillary services at any time during their stay. Typically, the social service department will manage ancillary services with communication and assistance from the nursing department. Based on record review and interview, facility failed to provide dental services to residents. This affected two residents (#26, #58) of four residents reviewed for dental services. The facility census was 57. Findings included: 1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including epilepsy, major depression, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of orders revealed Resident #26 had an order in place dated 10/16/21 to see audiologist, podiatrist, dentist, optometrist, and psychiatrist as needed. Review of a quarterly minimum data sets (MDS) dated [DATE] and 10/20/23 revealed Resident #15 had no difficulty chewing. Review of a care plan revised on 11/03/23 revealed Resident #26 had a care plan in place for being at risk for oral and dental health problems related to having her own natural teeth with some missing or broken, and reports of difficulty with chewing at times. Interventions included coordinate arrangements for dental care as needed or ordered. Review of a 360Care Consent dated 06/22/22 revealed Resident #26 consented to dental services. Further review of the medical record revealed no evidence a dental consult had been completed. Review of dental lists from 03/13/23 through 03/11/24 revealed Resident #26 was not listed as receiving a dental visit. Interview on 03/19/24 at 9:30 A.M. with Resident #26 revealed the teeth she had left hurt, and she had not been offered a dental appointment. Interview on 03/20/24 at 3:32 P.M. with Social Worker Designee (SWD) #144 revealed she was unsure of the last time Resident #26 was offered a dental appointment but Resident #26 will often decline care. Interview on 03/20/24 at 5:26 P.M. with Regional Clinical Support (RCS) #200 confirmed dental care plan stated Resident #26 had difficulties chewing and the MDS' completed on 03/07/24 and 10/20/23 were not coded correctly for difficulty chewing. 366173 Page 25 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility contract, review of dental list, observation, interview, and policy review the facility failed to ensure dental services were offered timely. This affected three residents (#3, #15, and #58) of six reviewed for dental services. Residents Affected - Few Findings included: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including needing assistance with personal care, emphysema, COPD, dysphagia, heart failure, and gastro-esophageal reflux disease. Review of Resident #3's census revealed the resident primary insurance since 07/28/23 was Medicaid. Review of Resident #3's admission assessments dated 07/21/23 and 10/02/23 revealed no evidence the dental section was completed. Review of Resident #3's admission MDS dated [DATE] revealed the resident had obvious or likely cavity or broken natural teeth. Review of Resident #3's oral/dental plan of care dated 08/04/23 revealed the resident had no upper teeth or dentures or partials. The resident reported some of her current teeth were broken and that she had difficulty chewing at times. The facility would coordinate arrangements for dental care, transportation as needed/ordered. Review of Resident #3's paper and electronic medical record revealed no evidence the resident had accepted or declined dental services. Review of dental visit list dated 12/04/23 and 03/11/24 revealed no evidence the resident was seen or referred to the dentist. Interview on 03/18/24 at 7:57 P.M., with Resident #3 revealed she had not seen a dentist since she had been admitted and her bottom teeth need pulled, and she needs upper dentures. Interview on 03/20/24 at 2:13 P.M., with the Director of Nursing (DON) revealed she could not find dental consents or evidence the resident had been seen by a dentist. The DON reported the facility had acquired a new ancillary service company and it was their understanding the company would obtain consents upon admission and arrange services. Interview on 03/20/24 at 2:41 P.M., with the Administrator and Social Worker (SW) #144 revealed it was the facility understanding the new ancillary company was going to get consents from the resident or representative and arrange appointments. The facility was not aware this was not being done. The SW reported the new company had taken over in October or November, however there was no evidence the resident had consents or was seen by the previous dental company as well. Interview on 03/21/24 8:14 A.M. with Administrator confirmed Resident #3's admission and re-admission assessment the dental section of the assessment form was left blank. 366173 Page 26 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/21/24 at 8:53 A.M., with the Director of Nursing (DON) confirmed the admission MDS as well as the care plan indicated the resident was having dental issue upon admission that was not addressed timely, however there was no evidence the resident had lost weight or had decreased intakes. Review of the Ancillary Contract dated 07/15/23 revealed the duties and responsibilities of each facility was to obtain consent for medical and healthcare services either from the resident or from the resident's responsible party, which consent shall remain valid in and in force for the entire length of stay of the resident unless otherwise revoked by the resident or the responsible party. Review of the facility policy and procedure titled Resident Healthcare Appointments/Ancillary Services (dated 02/2022) revealed upon admission or shortly thereafter ancillary services such as dental would be offered, and consent accepted or declined. Periodically throughout the residents stay they will be asked if given they consent for ancillary services. A resident may sign consent for ancillary services at any time during their stay. Typically, the social service department will manage ancillary services with communication and assistance from the nursing department. 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic obstructive pulmonary disease, Review of Resident#58's census revealed the resident received Medicaid insurance as of 02/29/24. Review of Resident #58's admission MDS dated [DATE] revealed the resident had his own natural teeth and there was no obvious or likely cavity or broken natural teeth. Review of admission assessment dated [DATE] and re-admission on [DATE] revealed the resident had his own teeth and no broken or carious teeth. Review of Resident #58's baseline care plan for ancillary services dated 12/18/23 revealed the goal provide necessary support in achieving ancillary needs. Review of Resident #58's oral/dental plan of care dated 12/20/23 revealed to coordinate arrangements for dental care, transportation as needed/as ordered. Review of Resident #58 paper and electronic medical record revealed no evidence the resident accepted or declined dental services. Review of dental visit list dated 03/11/24 and 12/04/23 revealed no evidence the resident was seen or referred to the dentist. Interview on 03/19/24 at 9:19 A.M., with Resident #58 revealed he had not seen a dentist since he had been admitted but he needs to see one. The residents' teeth appeared to discolored and poor condition. The resident had teeth missing on the bottom that was visible. The resident denied pain or discomfort. Interview on 03/20/24 at 2:13 P.M., with the Director of Nursing (DON) revealed she could not find dental consents or evidence the resident had been seen by a dentist. The DON reported the facility had acquired a new ancillary service company and it was their understanding that the company would obtain consents upon admission and arrange services. 366173 Page 27 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/20/24 at 2:41 P.M., with the Administrator and Social Worker (SW) #144 revealed it was the facility understanding the new ancillary company was going to get consents from the resident or representative and arrange appointments. The facility was not aware this was not being done. Review of the Ancillary Contract dated 07/15/23 revealed the duties and responsibilities of each facility was to obtain consent for medical and healthcare services either from the resident or from the resident's responsible party, which consent shall remain valid in and in force for the entire length of stay of the resident unless otherwise revoked by the resident or the responsible party. Review of the facility policy and procedure titled Resident Healthcare Appointments/Ancillary Services (dated 02/2022) revealed upon admission or shortly thereafter ancillary services such as dental would be offered, and consent accepted or declined. Periodically throughout the residents stay they will be asked if given they consent for ancillary services. A resident may sign consent for ancillary services at any time during their stay. Typically, the social service department will manage ancillary services with communication and assistance from the nursing department. 3. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anemia, and anxiety disorder. Review of quarterly MDS completed on 02/14/24 revealed Resident #15 did not have mouth or facial pain or discomfort. Review of care plan revealed no oral or dental care plan had been completed. Interview on 03/19/24 at 10:03 A.M. with Resident #15 revealed she had not been offered a dentist appointment since admission to the facility and she had a tooth that bothers her. Interview on 03/20/24 at 11:37 A.M. with Resident #15 revealed her tooth was still bothering her. Interview on 03/20/24 at 3:25 P.M. with Social Worker Designee (SWD) #144 revealed a consent for dental services had been signed for 360Care but she was unable to find a copy. SWD #144 stated she attempted to contact 360Care to obtain the consent with no success. SWD #144 confirmed Resident #15 was not on dental lists for 03/13/23, 04/11/23, 05/11/23, 06/20/23, 07/28/23, 08/15/23, 09/13/23, or 10/12/23. SWD #144 stated the facility was required to provide dental services as needed. Interview on 03/20/24 at 5:18 P.M. with Regional Clinical Support #199 revealed the MDS nurse would complete the initial care plan, but then nursing and social services should add in their specific care plans. RCS #199 confirmed Resident #15 did not have a dental care plan. Interview on 03/21/24 at 8:41 A.M. with MDS Nurse #200 revealed if dental concerns are not triggered on the MDS, a dental care plan would not be completed. MDS Nurse #200 stated the activities of daily living care plan would indicate what level of assistance each resident should receive, but would not specify what type of oral care would be provided. 366173 Page 28 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

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 and interview, the facility failed to store and prepare food under sanitary conditions. This had the potential to affect 56 of 57 residents who received food from the facility. The facility census was 57. Findings included: Observations on 03/18/24 from 7:03 P.M. to 7:18 P.M. during an initial tour of the kitchen revealed: one opened bag a macaroni noodles and one opened bag of bow tie pasta that were not dated, a Tupperware container of vanilla wafers that were not dated, two quarts of pears that were not dated, and a bag of shredded cheddar cheese was not dated. Additionally, the sanitizer water was tested, and the test strip did not change to the appropriate color. All findings were confirmed by Dietary Manager #128 and Regional Director of Operations #109 at the time of the observation. Observation of tray line for lunch on 03/20/24 revealed the following: -12:16 P.M. Dietary [NAME] (DC) #160 touched his ear then continued to plate noodles. -12:19 P.M. DM #128 coughed into his elbow, did not wash hands, then at 12:21 P.M. grabbed soup out of the steamer to prepare for a tray. -12:46 P.M. DM #128 coughed into his elbow, did not wash his hands, then put on oven mitts to get bread out of the oven. He proceeded by grabbing tongs to place bread in the hot well. -12:55 P.M. DM #300 retrieved lettuce and cheese from the refrigerator, did not wash his hands, donned one glove to his right hand, then grabbed a handful of lettuce and cheese with the gloved hand to make a salad. -1:00 P.M. DM #300 grabbed an onion from the fridge, did not wash his hands, donned gloves and began slicing the onion. -1:02 P.M. DC #160 scratched the back of his head and did not wash his hands. He continued to serve food. -1:04 P.M. DC #160 scratched his upper lip, did not wash hands, and continued serving food. Interview on 03/20/24 at 1:10 P.M. with DM #128 confirmed these findings. Review of a policy titled Hand Hygiene (dated 07/12/23) revealed all employees should practice hand hygiene whenever there is an incident of contact where contamination could occur such as touching hair, face, body, clothes or apron, sneezing, coughing or using a tissue. Review of a policy titled Food Storage (dated 09/08/21) revealed all food stock and products are to 366173 Page 29 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0812 Level of Harm - Minimal harm or potential for actual harm be stored in a safe and sanitary manner as well as being dated and used on a first in, first out basis. All food stock and products are stored in an approved sanitary storage container, of food quality plastic bags, covered, labeled as to contents, and dated. Residents Affected - Many 366173 Page 30 of 31 366173 03/25/2024 Continuing Healthcare at Beckett House 1280 Friendship Drive New Concord, OH 43762

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, McGreer's criteria review, and interview, the facility failed to ensure the criteria was met prior to antibiotics being administered. This affected one resident (#7) out of five residents reviewed for unnecessary medication. Facility census was 57. Residents Affected - Few Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE] and 11/09/23 with diagnoses that included atherosclerotic heart disease, hyponatremia, hypothyroidism, above knee right amputation, anemia in chronic kidney disease, and rheumatoid arthritis, The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact and always incontinent of urine. A general note dated 03/15/24 at 3:26 P.M. revealed the certified nurse practitioner (CNP) reviewed the urine cultures and ordered Ceftriaxone (antibiotic) one gram intramuscular at bedtime for four days for a urinary tract infection. The CNP was notified Resident #7 did not meet the criteria for an antibiotic to be ordered. Interview on 03/21/24 at 7:55 A.M. Registered Nurse (RN) #129 verified Resident #7 did not meet the criteria for antibiotic use due to there was no documentation of any signs or symptoms of a urinary tract infection. RN #129 verified Ceftriaxone was ordered and administered to Resident #7. McGreer's criteria for antibiotic usage for a urinary tract infection without an indwelling catheter must fulfill at least one sign or symptom of a urinary tract infection and at least one of the microbiologic criteria. 366173 Page 31 of 31