Health inspection·October 13, 2022

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences were provided for residents. This affected five (Resident #32, #41 #48, #56, and #86) of five residents reviewed for care conferences. The census was 128. Findings include: 1. Medical record review for Resident #86 revealed an admission date of 04/19/22. Medical diagnoses included chronic obstructive pulmonary disease (COPD) and bipolar disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/28/22, revealed Resident #86 was cognitively intact. Review of the medical record for Resident #86 revealed there was no care conference held with the resident upon admission or quarterly. Interview with Resident #86 on 09/26/22 at 1:16 P.M. revealed she couldn't remembers if she had been invited to or attended a care conference. Interview with the Administrator and Regional Nurse #420 on 09/28/22 at 11:15 A.M. confirmed there was no evidence of quarterly care conferences with Resident #86 having been completed. 2. Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included COPD, schizoaffective disorder, and diabetes. Review of quarterly MDS assessment, dated 09/13/22, revealed Resident #41 was cognitively intact. Review of Resident #41's medical record revealed there was no care conference on admission or quarterly for the the resident. Interview with Resident #41 on 09/26/22 at 2:48 P.M. revealed she didn't know if she had a care conference upon admission or quarterly. Interview with the Administrator and Regional Nurse #420 on 09/28/22 at 11:15 A.M. confirmed there was no evidence of quarterly care conferences with Resident #41 having been completed. 3. Medical record review for Resident #56 revealed an admission date of 08/03/16. Medical diagnoses Page 1 of 52 366201 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0553 included multiple sclerosis. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment dated [DATE] revealed Resident #56 was cognitively intact. Residents Affected - Some Review of Resident #56's medical record since 01/01/22 revealed there was no evidence of quarterly care conferences having been held with Resident #56. Interview with Resident #56 on 09/27/22 at 10:45 A.M. revealed she had not had any care conferences. Interview with the Administrator and Regional Nurse #420 on 09/28/22 at 11:15 A.M. confirmed there was no evidence of quarterly care conferences with Resident #56 having been completed. The Administrator stated their social worker walked out without notice and they were currently using an internal Licensed Social Worker (LSW) #501 and Social Services #500 who were onsite three to four days per week. The facility was currently looking for another social worker. 4. Review of the medical record for Resident #32 revealed an admission date of 09/20/21. Medical diagnoses included chronic respiratory failure, unspecified cirrhosis of liver, anxiety disorder, major depressive disorder, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition. Review of Resident #32's nurse's notes since 09/01/21 revealed there were no notes related to quarterly care conferences being conducted with Resident #32. Review of the care plan dated 09/21/21 revealed quarterly care conferences were not addressed in Resident #32's care plan. Review of the Interdisciplinary Team (IDT) Care Plan Conference Summary dated 05/16/22 revealed Resident #32 attended the care conference meeting on this date. There were no additional IDT Care Plan Conference Summary assessments completed for Resident #32 before or after 05/16/22. Interview on 09/27/22 at 8:38 A.M. with Resident #32 revealed the facility did not have a full time social worker on staff and he had not been invited to quarterly care conferences by any of the staff. Interview on 09/28/22 at 11:15 A.M. with the Nursing Home Administrator (NHA) and Regional Nurse (RN) #420 confirmed the facility did not have any evidence that quarterly care conferences were completed for Resident #32. The NHA and RN #420 stated the facility's social worker had walked out on the job without notice and the facility was actively recruiting for another full time social worker. 5. Review of the medical record for Resident #48 revealed an admission date on 04/13/21. Medical diagnoses included psychotic disorder with hallucinations due to a known physiological condition, vascular dementia with behavioral disturbance, generalized anxiety disorder, and cerebral infarction due to embolism (blood clot) of bilateral carotid arteries. Review of the quarterly MDS assessment, dated 07/05/22, revealed Resident #48 had intact cognition. 366201 Page 2 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0553 Level of Harm - Minimal harm or potential for actual harm Review of Resident #48's nurse's notes since 09/01/21 revealed there was no evidence of quarterly care conferences being conducted with Resident #48. Review of the care plan dated 04/14/21 revealed quarterly care conferences were not addressed in the plan of care for Resident #48. Residents Affected - Some Review of the IDT Care Plan Conference Summary assessment, dated 02/08/22, revealed Resident #48 attended the care conference on this date. There were no other IDT Care Plan Conference Summaries completed before or after 02/08/22. Interview on 09/27/22 at 11:36 A.M. with Resident #48 revealed Resident #48 did not recall ever attending a care plan conference with staff to discuss care goals and treatment plans. Interview on 09/28/22 at 11:15 A.M. with the NHA and RN #420 confirmed the facility did not have any evidence that quarterly care conferences were completed for Resident #32. The NHA and RN #420 stated the facility's social worker had walked out on the job without notice and the facility was actively recruiting for another full-time social worker. Review of the facility policy, Resident/Family Participation 72 Care Review-Assessment/Care Plans, revised 06/01/18, revealed the policy stated, the comprehensive care conference is scheduled after the completion of the comprehensive care plan and quarterly. Document the outcome of this meeting in the progress notes. This care conference should be attended by social services, dietary, activities, and nursing. 366201 Page 3 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on review of infection control records, observation, staff and resident interview, and policy review, the facility failed to ensure to residents were permitted to eat in the dining room. This affected two (Resident #12 and #17) of two residents reviewed for dining services. This had the potential to affect all 128 residents in the facility who receive meals from the kitchen. The census was 128. Residents Affected - Many Findings include: Review of the infection control records for COVID-19 revealed the last case of COVID-19 was on 09/15/22. Observations on 09/26/22 from 8:00 A.M. to 8:30 A.M. and 12:00 P.M. to 12:30 P.M., and on 09/27/22 from 8:00 A.M. to 8:30 A.M. and 12:00 P.M. to 12:30 P.M., revealed no residents were in the dining room eating meals. Interview with Resident #12 on 09/28/22 at 8:42 A.M. revealed every time there was an outbreak of COVID-19 the dining room was closed. The interview further revealed the dining room had remained closed and she would like to participate in dining services. Interview with Resident #17 on 09/28/22 at 11:49 A.M. revealed she would like to go to the dining room for meals if it was open. She stated it had been closed for quite some time due to COVID-19. Interview with Regional Nurse (RN) #420 on 09/29/22 at 3:00 P.M. confirmed the facility had not been having communal dining for residents without COVID-19 and the last positive COVID-19 case was on 09/15/22. Review of the policy titled Communal Dining and Activities, dated 02/01/22, revealed it was the policy of the facility to ensure the residents can safely participate in communal dining and activities during the COVID-19 pandemic. The up-to-date vaccinated resident may choose to not socially distance and may have contact, but must be encouraged to wear a mask if all residents in the dining area are not fully vaccinated. Unvaccinated and not-up-to date vaccinated residents must socially distance from others and be encouraged to wear a mask at all times when dining except when eating. 366201 Page 4 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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, staff interview, and review of beneficiary notices, the facility failed to provide the appropriate beneficiary notices (Notice of Medicare Non-Coverage and Advanced Beneficiary Notice) to three residents. This affected three (Residents #44, #92, and #115) of three residents reviewed for beneficiary notices. The facility census was 128. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #44 revealed an admission date on 03/11/22. Medical diagnoses included chronic hepatic failure without coma, Type II Diabetes Mellitus with hyperglycemia, unspecified viral hepatitis C, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition. Resident #44 required supervision to limited assistance from one to two staff to complete activities of daily living (ADLs). Review of the beneficiary notices list from the last six months revealed Resident #44 was cut from Medicare Part A therapy services on 05/30/22 and still had therapy days remaining. Resident #44 remained in the facility. Review of the Notice Of Medicare Non-Coverage (NOMNC) for Resident #44 revealed the notice was provided to the resident on 05/30/22 which was the same day as the resident's last day of service. Review of the Advanced Beneficiary Notice (ABN) for Resident #44 revealed the notice was provided on 05/30/22, which was the same day as the resident's last day of service. The notice did not include an estimated cost of services should Resident #44 choose to continue therapy services. The notice also did not indicate whether or not Resident #44 preferred to continue with therapy services or agreed to stop therapy services. Interview on 09/29/22 at 10:33 A.M. with the Business Office Manager (BOM) #214 confirmed Resident #44 was not provided with either notice at least 48 hours in advance of being cut from therapy services. The BOM also confirmed the ABN notice did not include an estimated cost for Resident #44 to continue receiving therapy services if he chose to do so. 2. Review of the medical record for Resident #92 revealed an admission date of 04/25/22. Medical diagnoses included cerebral ischemia, repeated falls, and unspecified dementia without behavioral disturbance. Review of the quarterly MDS assessment dated [DATE] revealed Resident #92 had severely impaired cognition. Resident #92 required extensive assistance to total dependence on two staff to complete ADLs. Review of the beneficiary notices list for the last six months revealed Resident #92 was cut from Medicare Part A therapy services on 08/02/22 and still had therapy days remaining. Resident #92 remained in the facility. 366201 Page 5 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the NOMNC notice for Resident #92 revealed the notice was provided on 08/02/22 which was the same day as the last day of service. Review of the ABN notice for Resident #92 revealed the notice was provided on 08/02/22 which was the same day as the last day of service and did not include an estimated cost of services should the resident chose to continue receiving therapy services. Interview on 09/29/22 at 10:33 A.M. with BOM #214 confirmed Resident #92 was not provided with either notice at least 48 hours in advance of being cut from therapy services. The BOM also confirmed the ABN notice did not include an estimated cost for Resident #92 to continue receiving therapy services if he chose to do so. 3. Review of the medical record for Resident #115 revealed an admission date on 05/31/22. Medical diagnoses included chronic obstructive pulmonary disease, Type II Diabetes Mellitus without complications, Stage III chronic kidney disease, and acquired absences of right and left legs below the knee. Review of the quarterly MDS assessment dated [DATE] revealed Resident #115 had intact cognition. Resident #115 required extensive assistance from two staff to complete ADLs. Review of the beneficiary notices from the last six months revealed Resident #115 was cut from Medicare Part A therapy services on 09/21/22 and still had therapy days remaining. Resident #115 remained in the facility. Review of the ABN notice revealed Resident #115 was provided the notice on 09/19/22 but the notice did not include an estimated cost of services should Resident #11 choose to continue with therapy services. Interview on 09/29/22 at 10:33 A.M. with BOM #214 confirmed the ABN notice did not include an estimated cost for Resident #115 to continue receiving therapy services if he chose to do so. 366201 Page 6 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff and resident interview, and facility policy review, the facility failed to ensure a homelike environment was provided for residents. This affected one (#9) out of 128 residents reviewed during the screening process. The census was 128. Findings include: Observation on 09/27/22 at 11:00 A.M. revealed Resident #9 was sitting in bed with only a shirt on and looking out his window which had window blind that was not down and the window overlooked the parking lot. Interview on 09/28/22 at 3:02 P.M. with Resident #9 revealed his window blind was broken and would not go down. Resident 9 stated his window was overlooking the parking lot. Resident #9 stated the shower curtain was hanging and broken in the shower in his room. Resident #9 stated maintenance was aware of his window blind and shower curtain however maintenance had never come back to fix either. Observation on 09/28/22 at 3:10 P.M. revealed Resident #9's window blind would not go down. The window blind was open roughly 18 inches from the window ledge. Unit Manager #318 tried to pull the window blind down from either angle but was unable. The shower curtain in Resident #9's bathroom was hanging and was not hanging correctly in order for Resident #9 to take a shower. Interview on 09/28/22 at 3:12 P.M. with Maintenance Assistant #505 revealed Resident #9 told him that he needed the window blind fixed and he was also aware of the shower curtain that needed to be replaced. Maintenance Assistant #505 stated he had to special order the window blind because it was too wide. Review of the policy titled Quality-of-Life Home Like Environment, dated 05/2017, revealed the staff should provide person centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 366201 Page 7 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on medical record review, resident and staff interviews, review of a Self-Reported Incident (SRI), review of the activity log, and facility policy review, the facility failed to ensure residents were free from verbal abuse by another resident. This resulted in actual Psychosocial Harm when Resident #63 was cursed at, physically intimidated, and called inappropriate names by Resident #128 resulting in Resident #63 becoming afraid of Resident #128 and not attending activities or leaving her room for two days following the incident. This affected one (Resident #63) of five residents reviewed for abuse. The facility census was 128. Findings include: Review of Resident #63's medical record revealed an admission date of 01/25/17. Medical diagnoses included but were not limited to hemiplegia, hemiparesis, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/22, revealed Resident #63 had moderately impaired cognition. Resident #63 required extensive assistance from two staff for bed mobility and transfers, and supervision for locomotion via wheelchair. Resident #63 did not have any behaviors indicated in the assessment. Review of Resident #63's care plan, revised 11/30/20, revealed Resident #63 preferred to structure her own day of activities including attending activities such as bingo, arts and crafts, and socializing with friends and peers. Resident #63 had a self-care deficit due to stroke with hemiplegia and hemiparesis. Interventions included bed mobility/transfers per staff assistance as needed and eating with staff set up help. Resident #63 propelled herself in a wheelchair and wore a vinyl glove on the hand she propelled herself with. Resident #63 had a history of depression and or anxiety and a history of physical altercations with another resident. Interventions included one on one meetings as needed, ensure Resident #63's physiological needs are met, and provide a calm, reassuring and nonthreatening environment. Review of Resident #63's nurse's notes revealed on 09/23/22 at 6:07 P.M., the Nursing Home Administrator (NHA) called Resident #63's son to inform him Resident #63 was involved in a negative verbal conversation from a male resident (later identified as Resident #128). An SRI was submitted and further investigation would be completed. There were no additional notes related to the incident. On 09/28/22 at 6:30 P.M., MDS Nurse #222 completed an interview with Resident #63. Resident #63 stated she preferred to keep to herself as to not have any issues or incidents where she is involved. Resident #63 stated she felt mostly safe. Resident #63 stated she continued to be leary or apprehensive about engaging with others at that time. Review of the psychiatric note, dated 09/30/22 at 1:00 A.M., revealed Resident #63 was seen from 12:02 P.M. to 12:18 P.M. by Psych Physician (PP) #529. During the session, Resident #63 presented as anxious, tearful/crying, cooperative, and engaged. There was no indication of any follow up with Resident #63 related to the verbal altercation that occurred with Resident #128 on 09/23/22. Review of the activity logs, dated 08/2022 and 09/2022, revealed Resident #63 engaged in group activities on 08/05/22, 08/18/22, 08/19/22, 08/25/22, 08/29/22, 09/05/22, and 09/12/22. Resident #63 did not attend any activities on 09/23/22, 09/24/22, or 09/25/22. 366201 Page 8 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of the closed medical record for Resident #128 revealed an admission date on 08/27/21 and a discharge date on 09/26/22. Medical diagnoses included but were not limited to alcohol dependence, dementia with behavioral disturbance, borderline personality disorder, and generalized anxiety disorder. Review of Resident #128's Annual MDS assessment, dated 08/11/22, revealed Resident #128 had intact cognition. No signs or symptoms of delirium were indicated. No behavioral symptoms were indicated on the assessment. Review of Resident #128's nurse's notes revealed on 09/23/22 at 6:16 P.M., the NHA called Resident #128's wife to inform her Resident #128 was involved in a negative verbal conversation toward two female residents. Resident #128 was the verbal aggressor in the situation. On 09/24/22 at 12:29 A.M., Licensed Practical Nurse (LPN) #333 noted Resident #128 was both physically and verbally aggressive towards staff and other residents. Resident #128 had called Resident #63, who was on another hall, a (expletive). Review of Resident #128's care plan, dated 08/30/21, revealed Resident #128 exhibited behaviors of keeping alcoholic beverages in his room, drinking in the facility and being intoxicated, refusing medications at times, using inappropriate language/profanity as regular communication with staff and residents, making unwanted advances towards female residents at times, yelling and cursing at staff and other residents. Interventions included document behaviors per behavior management program, educate resident on facility policy of alcoholic beverages and risks of intoxication, social services to offer addiction intervention services and evaluation as needed, every 15 minute checks on resident's activity and location (09/23/22), maintain a safe environment, remove resident from situation, and notify physician and psych services for increases in behavioral symptoms. Review of the SRI, dated 09/23/22, revealed Resident #63's written statement stated she was sitting in the facility community room on 09/22/22, speaking with Resident #70, when Resident #128 approached her. Resident #63 felt like he may have wanted to harm me by the way he was looking at her and then Resident #128 got close to her by standing over her. Resident #128 called Resident #63 out of my name several times and was still looking down on her. Resident #63 wrote I got very scared because I thought he would do harm to me. He scared me and indicated she was elderly and paralyzed on the left side. Resident #63 continued, He kept calling me nasty names and standing over me, looking mean at me and cursing at me. Now I am nervous to come out of my room to be able to go to speak to my friends. I enjoy speaking with people but I am in fear of Resident #128. Review of the written witness statement from Resident #70, dated 09/23/22, revealed on 09/22/22, Resident #128 entered the community room from the smoking area and went toward her friend (Resident #63) looking for trouble. Resident #70 got up to protect Resident #63 from Resident #128. Resident #128 came nose to nose with me and said do not test me. Resident #128 backed off for only a few seconds and then turned around and came back to the community room and went towards Resident #63 again. Resident #128 called Resident #63 a (expletive), (expletive) and stupid. Resident #70 stood up again to intervene between Resident #128 and Resident #63. Review of the written witness statement from Resident #283, dated 09/23/22, revealed he saw a man (later identified as Resident #128) cussing at two ladies (later identified as Residents #63 and #70). Resident #128 said he would slap the (expletive) out of them and was calling them (expletive) and other words. 366201 Page 9 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0600 Level of Harm - Actual harm Residents Affected - Few Interview on 09/28/22 at 1:55 P.M. with the Director of Nursing (DON) revealed she had not witnessed Resident #128 be physically aggressive with any staff or residents, but Resident #128 was verbally aggressive. Resident #128 drank alcohol usually after hours and gave other residents money to get the alcohol for him. On 09/23/22, Resident #128 had a verbal altercation with two female residents (later identified as Resident #63 and #70) during which Resident #128 called the female residents names and was threatening toward them. Resident #128 was placed on 15 minute checks, was being seen by psych services, and was on medication for alcohol abuse. Interview on 09/28/22 at 2:13 P.M. with Medical Records (MR) #203 revealed she was not clinical but was familiar with Resident #128. MR #203 stated Resident #128 was easily agitated and became verbally aggressive toward staff and other residents, especially when he was drinking alcohol. MR #203 stated she had witnessed Resident #128 engage in verbal altercations during the day and had heard from staff that altercations also occurred at night. Interview on 09/28/22 at 3:25 P.M. with Resident #70 confirmed she was involved in a verbal altercation with Resident #128 on the evening of 09/22/22. Resident #70 stated she was talking with Resident #63 when Resident #128 entered the same area and started yelling and cursing at Resident #63. Resident #128 called Resident #63 (expletive) and (expletive). Resident #128 went directly to Resident #63 and got in her face and was nose to nose with her, standing over top of her, and pointing his finger in her face. Resident #70 stated she was scared for Resident #63. Resident #70 stated, I'm sure he was on something or was intoxicated. No facility staff were present to intervene when the incident occurred but she intervened to defend Resident #63. Resident #70 stated Resident #128 was completely unprovoked. Resident #70 stated she carried on with her normal routine following the incident but Resident #63 was scared to come out of her room for a couple of days. Interview on 09/28/22 at 3:45 P.M. with Resident #63 confirmed Resident #128 walked up to her and started yelling and cursing at her and calling her foul names, (expletive) and (expletive). Resident #63 stated Resident #128 was standing over top of her and she thought he was going to hit me. Resident #63 stated Resident #70 helped her. Resident #63 stated she was scared and intimidated by Resident #128. Resident #63 stated she stayed close to her room for a couple of days because she did not want to run into him again. Resident #63 stated she talked with Resident #70 but that was all she engaged in for the weekend following the incident. Interview on 09/29/22 at 8:47 A.M. with Unit Manager (UM) #318 confirmed a verbal altercation between Resident #128, Resident #63, and Resident #70 occurred on 09/22/22 around 8:00 P.M. Resident #70 reported the incident to her. UM #318 stated Resident #70 informed her that she and Resident #63 were approached by Resident #128 who was clearly on something or intoxicated and went after Resident #63. Resident #283 witnessed Resident #128 calling Resident #63 foul names including, (expletive), (expletive), (expletive). UM #318 stated both Resident #63 and Resident #70 reported being scared and intimidated by Resident #128. UM #318 confirmed Resident #63 did not leave her room as much as usual following the incident. Interview on 09/29/22 at 1:40 P.M. with Activities Director (AD) #206 confirmed Resident #63 liked to engage in group activities and regularly left her room prior to the incident on 09/22/22. Review of the facility policy, Abuse Prevention Program, revised 03/2021, revealed the policy stated, our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. 366201 Page 10 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #93 revealed an admission date of 08/03/16 and the diagnoses of dementia, schizoaffective disorder, anxiety, and Alzheimer's disease. Residents Affected - Some Review of the quarterly MDS assessment dated [DATE], revealed Resident #93 had intact cognition and required supervision of one staff for bed mobility and walking, and required limited assistance of one staff for transfers. It also stated she had verbal behaviors directed towards others multiple times and other behavior symptoms not directed towards others multiple times. Review of the care plan dated 07/21/21 for Resident #93 revealed the resident may exhibit episodes of verbal aggression, repetitive sentences in a loud voice, and refusing ancillary services with interventions to approach the resident in a calm and friendly manner, document behaviors per the behavior management program, if the resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure and reapproach if needed, and remove the resident from the situation. The care plan also revealed Resident #93 received psychotropic medications and was at risk for adverse side effects and was receiving antidepressant, antipsychotic, and antianxiety medications related to bipolar disorder, unspecified dementia without behaviors, and schizoaffective disorder. Interventions included administer medications per orders and observe for side effects and adverse reactions of medications. Review of the nurses notes dated 06/30/22 at 8:05 P.M. revealed Resident #93 was noted to have a physical altercation with another resident (#63). The nurse was notified that both residents were kicking each other. The residents were separated and taken to a safe location. Skin assessments showed no new injuries and vital signs were within normal limits. Resident #93 denied pain/discomfort. The nurse practitioner, responsible party, and Director of Nursing (DON) were notified. Resident #93 was noted to be on 15 minute checks for 24 hours. Staff were to continue to monitor. 4. Review of the medical record for Resident #63 revealed an admission date of 01/24/17 and the diagnoses of hemiplegia, hemiparesis, anxiety, depression, lack of coordination, muscle weakness, and difficulty walking. Review of the annual MDS assessment dated [DATE], revealed Resident #63 had moderately impaired cognition, required extensive two staff assistance for bed mobility and transfers, and required supervision for locomotion via wheelchair. The assessment stated Resident #63 had no behaviors. Review of the care plan, dated 02/04/20, for Resident #63 revealed Resident #63 received psychotropic medication (or psychotropic like medication) and was at risk for adverse side effects. She took an antidepressant for her depression and her insomnia with interventions to review behaviors/interventions and alternate therapies attempted and their effectiveness per policy, and observe for adverse reactions to antidepressant therapy such as changes in behavior/mood/cognition. Review of the nurses notes, dated 06/30/22 at 8:48 P.M., revealed Resident #63 and another resident (Resident #93) were kicking each other by the dining room hallway. They were both separated and taken to their units. Resident #63 stated Resident #93 kicked her first, called her a (expletive), and she could not understand what else she was saying. Resident #63 then proceeded to kick Resident #93 back. Both residents started kicking each other. No skin issues were noted upon assessment. Vital signs were within normal limits and the physician and responsible parties were notified. 366201 Page 11 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/28/22 at 11:51 A.M. with Resident #63 revealed Resident #93 kicked her in her knee cap a few months ago. Resident #63 stated Resident #93 did it because she is mean and hateful. She stated staff witnessed the incident and saw/heard it. Review of the incident investigation form, dated 06/30/22, revealed Resident #63 and another resident (#93) started kicking each other. Both residents had a diagnoses of dementia. It stated there were no injuries noted to either resident and the residents were separated and returned back to their units. The residents returned to baseline after returning to their units. The physicians and families were updated. Interview on 09/29/22 at 10:06 A.M. with the DON confirmed the incident occurred on 06/30/22 between Resident #63 and Resident #93. The DON stated she was on vacation at the time and the Administrator was different than the current one. Interview on 09/29/22 at 2:44 P.M. with the DON confirmed there was no SRI completed for the incident between Resident #63 and Resident #93 and the incident was not reported to the state survey agency. Interview on 09/29/22 at 3:29 P.M. with the DON confirmed there were no additional investigation pieces for the incident between Resident #63 and Resident #93 besides the incident report. There were no witness statements, interviews, investigation, or follow up. Review of the facility policy and procedure titled, Abuse Prevention Program, dated March 2021, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also stated employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Administrator or his/her designee. The policy stated when an alleged or suspected case of mistreatment, neglect, exploitation, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately notify the state agency. The policy stated the facility will investigate the suspected incident, and it will consist of a minimum of a medical record review, interviews from the person reporting, interview with the witnesses, interview with the residents, interview with physicians, interview with other staff who had contact with the residents during the period of the alleged incident, and review all events leading up to the alleged incident. The policy stated the Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency. Based on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to implement their abuse policies and procedures. This affected four (Residents #63, #72, #93 and former Resident #128) of six residents reviewed for abuse. The facility census was 128. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date on 03/09/20. Medical diagnoses included unspecified dementia, chronic obstructive pulmonary disease (COPD), unspecified psychosis, alcohol abuse, and alcoholic cirrhosis of liver. 366201 Page 12 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had mild cognitive impairment. Resident #72 required limited assistance from one staff to complete activities of daily living (ADLs). No behaviors were noted in the assessment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 had severely impaired cognition. Resident #72 displayed continuous delirium symptoms, verbal behaviors towards others, rejection of care, and wandering. Review of the progress note dated 04/23/22 at 9:03 P.M. revealed Resident #128 pushed Resident #72 to the floor in the left side sitting position. A head-to-toe assessment, neurological assessment, and pain assessment were completed. Resident #72 was alert and oriented with intermittent confusion, no skin discoloration or bruises were observed. Resident #72 denied any pain. Resident #72 was assisted off the floor to a standing position and was redirected back to his room. Resident #72's vital signs were within normal limits. Resident #72's guardian was notified via voicemail. The Director of Nursing (DON) and on-call physician were notified of the incident. 2. Review of the closed medical record for former Resident #128 revealed an admission date on 08/27/21 and discharge date on 09/26/22. Medical diagnoses included alcohol dependence, alcoholic hepatitis, dementia with behavioral disturbance, generalized anxiety disorder, borderline personality disorder, and metabolic encephalopathy. Review of the admission MDS assessment dated [DATE] revealed Resident #128 had intact cognition. Resident #128 required supervision to limited assistance from one staff to complete ADLs. No behaviors were noted in the assessment. Review of the nurse's notes revealed on 04/23/22, Resident #128 pushed Resident #72 to the floor. Resident #128 was unprovoked and intoxicated at the time of the incident. Review of the Physical Incident Report dated 04/23/22 at 7:04 P.M. revealed Resident #128 pushed Resident #72 when Resident #72 entered Resident #128's room. Resident #72 did not take any of Resident #128's belongings or provoke Resident #128. The residents were separated. Resident #128 stated, Get the (expletive) out of my room. I told him to stay the (expletive) out of my room. A head-to-toe assessment, neurological assessment and pain assessment were completed on Resident #72. Resident #128 was alert and oriented but appeared intoxicated at the time of the incident. Licensed Practical Nurse (LPN) #333 attempted to educate Resident #128 but the resident became aggressive both physically and verbally with staff and continued to use foul language, including (expletive) and (expletive) words. Every 15-minute checks were initiated. Certified Nurse Practitioner (CNP) #530 was notified. Review of the facility's Self-Reported Incidents (SRI's) for the last year revealed there was not a SRI opened related to the physical and verbal altercation between Resident #72 and Resident #128. Interview on 09/28/22 at 1:55 P.M. with the DON revealed she had not witnessed Resident #128 being physically aggressive toward any residents or staff but the resident was verbally aggressive. Resident #128 drank alcohol at the facility usually after hours. Resident #128 had been placed on 15-minute checks, was seen by psychiatric services, and received medication for alcohol abuse. The DON stated, that's just him. Interview on 09/28/22 at 2:13 P.M. with Medical Records (MR) #203 revealed she was not clinical but was familiar with Resident #128. MR #203 stated Resident #128 was easily agitated and became 366201 Page 13 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some verbally aggressive toward staff and other residents, especially when he was drinking alcohol. MR #203 stated she had witnessed Resident #128 engaged in verbal altercations during the day and had heard from other staff altercations also occurred at night. Interview via telephone on 09/28/22 at 2:30 P.M. with Nursing Home Administrator (NHA) #531 (previous Administrator) revealed he was familiar with Resident #128. NHA #531 confirmed Resident #128 had a history of alcohol abuse and would frequently leave the facility. Resident #128 was alert and oriented. Resident #128 had a physician order to allow him to consume one can of beer daily but he frequently drank more than that and brought outside alcohol into the facility. NHA #531 denied knowledge of Resident #128 being physically aggressive with any residents or staff but could be verbally aggressive. Interview on 09/28/22 at 5:27 P.M. with LPN #333 revealed Resident #128 was intoxicated frequently at the facility. LPN #333 stated the resident was not compliant with only drinking one beer daily per physician orders and frequently found alcohol in Resident #128's room including bottles of liquor and beer. LPN #333 stated Resident #128 was verbally aggressive when intoxicated. LPN #333 denied knowledge of any physical altercations that Resident #128 was involved in but confirmed he completed the incident report dated 04/23/22. Interview on 09/29/22 at 10:00 A.M. with the NHA confirmed an SRI was not opened, the incident was not reported to the state survey agency, and there was no further investigation following the physical altercation between Residents #72 and #128. 366201 Page 14 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #93 revealed an admission date of 08/03/16 and the diagnoses of dementia, schizoaffective disorder, anxiety, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #93 had intact cognition and required supervision of one staff for bed mobility and walking, and required limited assistance of one staff for transfers. It also stated she had verbal behaviors directed towards others multiple times and other behavior symptoms not directed towards others multiple times. Review of the care plan dated 07/21/21 for Resident #93 revealed the resident may exhibit episodes of verbal aggression, repetitive sentences in a loud voice, and refusing ancillary services with interventions to approach the resident in a calm and friendly manner, document behaviors per the behavior management program, if the resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure and reapproach if needed, and remove the resident from the situation. The care plan also revealed Resident #93 received psychotropic medications and was at risk for adverse side effects and was receiving antidepressant, antipsychotic, and antianxiety medications related to bipolar disorder, unspecified dementia without behaviors, and schizoaffective disorder. Interventions included administer medications per orders and observe for side effects and adverse reactions of medications. Review of the nurses notes dated 06/30/22 at 8:05 P.M. revealed Resident #93 was noted to have a physical altercation with another resident (#63). The nurse was notified that both residents were kicking each other. The residents were separated and taken to a safe location. Skin assessments showed no new injuries and vital signs were within normal limits. Resident #93 denied pain/discomfort. The nurse practitioner, responsible party, and Director of Nursing (DON) were notified. Resident #93 was noted to be on 15 minute checks for 24 hours. Staff were to continue to monitor. 4. Review of the medical record for Resident #63 revealed an admission date of 01/24/17 and the diagnoses of hemiplegia, hemiparesis, anxiety, depression, lack of coordination, muscle weakness, and difficulty walking. Review of the annual MDS assessment dated [DATE], revealed Resident #63 had moderately impaired cognition, required extensive two staff assistance for bed mobility and transfers, and required supervision for locomotion via wheelchair. The assessment stated Resident #63 had no behaviors. Review of the care plan, dated 02/04/20, for Resident #63 revealed Resident #63 received psychotropic medication (or psychotropic like medication) and was at risk for adverse side effects. She took an antidepressant for her depression and her insomnia with interventions to review behaviors/interventions and alternate therapies attempted and their effectiveness per policy, and observe for adverse reactions to antidepressant therapy such as changes in behavior/mood/cognition. Review of the nurses notes, dated 06/30/22 at 8:48 P.M., revealed Resident #63 and another resident (Resident #93) were kicking each other by the dining room hallway. They were both separated and taken to their units. Resident #63 stated Resident #93 kicked her first, called her a (expletive), and she could not understand what else she was saying. Resident #63 then proceeded to kick Resident #93 back. Both residents started kicking each other. No skin issues were noted upon assessment. Vital 366201 Page 15 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0609 signs were within normal limits and the physician and responsible parties were notified. Level of Harm - Minimal harm or potential for actual harm Interview on 09/28/22 at 11:51 A.M. with Resident #63 revealed Resident #93 kicked her in her knee cap a few months ago. Resident #63 stated Resident #93 did it because she is mean and hateful. She stated staff witnessed the incident and saw/heard it. Residents Affected - Some Review of the incident investigation form, dated 06/30/22, revealed Resident #63 and another resident (#93) started kicking each other. Both residents had a diagnoses of dementia. It stated there were no injuries noted to either resident and the residents were separated and returned back to their units. The residents returned to baseline after returning to their units. The physicians and families were updated. Interview on 09/29/22 at 10:06 A.M. with the DON confirmed the incident occurred on 06/30/22 between Resident #63 and Resident #93. The DON stated she was on vacation at the time and the Administrator was different than the current one. Interview on 09/29/22 at 2:44 P.M. with the DON confirmed there was no SRI completed for the incident between Resident #63 and Resident #93 and the incident was not reported to the state survey agency. Review of the facility policy and procedure titled, Abuse Prevention Program, dated March 2021, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also stated employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Administrator or his/her designee. The policy stated when an alleged or suspected case of mistreatment, neglect, exploitation, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately notify the state agency. The policy stated the facility will investigate the suspected incident, and it will consist of a minimum of a medical record review, interviews from the person reporting, interview with the witnesses, interview with the residents, interview with physicians, interview with other staff who had contact with the residents during the period of the alleged incident, and review all events leading up to the alleged incident. The policy stated the Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency. Based on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to ensure allegations of abuse were reported to the state survey agency. This affected four (Residents #63, #72, #93, and former Resident #128) of six residents reviewed for abuse. The facility census was 128. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date on 03/09/20. Medical diagnoses included unspecified dementia, chronic obstructive pulmonary disease (COPD), unspecified psychosis, alcohol abuse, and alcoholic cirrhosis of liver. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had mild 366201 Page 16 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitive impairment. Resident #72 required limited assistance from one staff to complete activities of daily living (ADLs). No behaviors were noted in the assessment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 had severely impaired cognition. Resident #72 displayed continuous delirium symptoms, verbal behaviors towards others, rejection of care, and wandering. Review of the progress note dated 04/23/22 at 9:03 P.M. revealed Resident #128 pushed Resident #72 to the floor in the left side sitting position. A head-to-toe assessment, neurological assessment, and pain assessment were completed. Resident #72 was alert and oriented with intermittent confusion, no skin discoloration or bruises were observed. Resident #72 denied any pain. Resident #72 was assisted off the floor to a standing position and was redirected back to his room. Resident #72's vital signs were within normal limits. Resident #72's guardian was notified via voicemail. The Director of Nursing (DON) and on-call physician were notified of the incident. 2. Review of the closed medical record for former Resident #128 revealed an admission date on 08/27/21 and discharge date on 09/26/22. Medical diagnoses included alcohol dependence, alcoholic hepatitis, dementia with behavioral disturbance, generalized anxiety disorder, borderline personality disorder, and metabolic encephalopathy. Review of the admission MDS assessment dated [DATE] revealed Resident #128 had intact cognition. Resident #128 required supervision to limited assistance from one staff to complete ADLs. No behaviors were noted in the assessment. Review of the nurse's notes revealed on 04/23/22, Resident #128 pushed Resident #72 to the floor. Resident #128 was unprovoked and intoxicated at the time of the incident. Review of the Physical Incident Report dated 04/23/22 at 7:04 P.M. revealed Resident #128 pushed Resident #72 when Resident #72 entered Resident #128's room. Resident #72 did not take any of Resident #128's belongings or provoke Resident #128. The residents were separated. Resident #128 stated, Get the (expletive) out of my room. I told him to stay the (expletive) out of my room. A head-to-toe assessment, neurological assessment and pain assessment were completed on Resident #72. Resident #128 was alert and oriented but appeared intoxicated at the time of the incident. Licensed Practical Nurse (LPN) #333 attempted to educate Resident #128 but the resident became aggressive both physically and verbally with staff and continued to use foul language, including (expletive) and (expletive) words. Every 15-minute checks were initiated. Certified Nurse Practitioner (CNP) #530 was notified. Review of the facility's Self-Reported Incidents (SRI's) for the last year revealed there was not a SRI opened related to the physical and verbal altercation between Resident #72 and Resident #128. Interview on 09/28/22 at 1:55 P.M. with the DON revealed she had not witnessed Resident #128 being physically aggressive toward any residents or staff but the resident was verbally aggressive. Resident #128 drank alcohol at the facility usually after hours. Resident #128 had been placed on 15-minute checks, was seen by psychiatric services, and received medication for alcohol abuse. The DON stated, that's just him. Interview on 09/28/22 at 2:13 P.M. with Medical Records (MR) #203 revealed she was not clinical but was familiar with Resident #128. MR #203 stated Resident #128 was easily agitated and became verbally aggressive toward staff and other residents, especially when he was drinking alcohol. MR #203 366201 Page 17 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she had witnessed Resident #128 engaged in verbal altercations during the day and had heard from other staff altercations also occurred at night. Interview via telephone on 09/28/22 at 2:30 P.M. with Nursing Home Administrator (NHA) #531 (previous Administrator) revealed he was familiar with Resident #128. NHA #531 confirmed Resident #128 had a history of alcohol abuse and would frequently leave the facility. Resident #128 was alert and oriented. Resident #128 had a physician order to allow him to consume one can of beer daily but he frequently drank more than that and brought outside alcohol into the facility. NHA #531 denied knowledge of Resident #128 being physically aggressive with any residents or staff but could be verbally aggressive. Interview on 09/28/22 at 5:27 P.M. with LPN #333 revealed Resident #128 was intoxicated frequently at the facility. LPN #333 stated the resident was not compliant with only drinking one beer daily per physician orders and frequently found alcohol in Resident #128's room including bottles of liquor and beer. LPN #333 stated Resident #128 was verbally aggressive when intoxicated. LPN #333 denied knowledge of any physical altercations that Resident #128 was involved in but confirmed he completed the incident report dated 04/23/22. Interview on 09/29/22 at 10:00 A.M. with the NHA confirmed an SRI was not opened and the incident between Residents #72 and #128 was not reported to the state survey agency. 366201 Page 18 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #93 revealed an admission date of 08/03/16 and the diagnoses of dementia, schizoaffective disorder, anxiety, and Alzheimer's disease. Residents Affected - Some Review of the quarterly MDS assessment dated [DATE], revealed Resident #93 had intact cognition and required supervision of one staff for bed mobility and walking, and required limited assistance of one staff for transfers. It also stated she had verbal behaviors directed towards others multiple times and other behavior symptoms not directed towards others multiple times. Review of the care plan dated 07/21/21 for Resident #93 revealed the resident may exhibit episodes of verbal aggression, repetitive sentences in a loud voice, and refusing ancillary services with interventions to approach the resident in a calm and friendly manner, document behaviors per the behavior management program, if the resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure and reapproach if needed, and remove the resident from the situation. The care plan also revealed Resident #93 received psychotropic medications and was at risk for adverse side effects and was receiving antidepressant, antipsychotic, and antianxiety medications related to bipolar disorder, unspecified dementia without behaviors, and schizoaffective disorder. Interventions included administer medications per orders and observe for side effects and adverse reactions of medications. Review of the nurses notes dated 06/30/22 at 8:05 P.M. revealed Resident #93 was noted to have a physical altercation with another resident (#63). The nurse was notified that both residents were kicking each other. The residents were separated and taken to a safe location. Skin assessments showed no new injuries and vital signs were within normal limits. Resident #93 denied pain/discomfort. The nurse practitioner, responsible party, and Director of Nursing (DON) were notified. Resident #93 was noted to be on 15 minute checks for 24 hours. Staff were to continue to monitor. 4. Review of the medical record for Resident #63 revealed an admission date of 01/24/17 and the diagnoses of hemiplegia, hemiparesis, anxiety, depression, lack of coordination, muscle weakness, and difficulty walking. Review of the annual MDS assessment dated [DATE], revealed Resident #63 had moderately impaired cognition, required extensive two staff assistance for bed mobility and transfers, and required supervision for locomotion via wheelchair. The assessment stated Resident #63 had no behaviors. Review of the care plan, dated 02/04/20, for Resident #63 revealed Resident #63 received psychotropic medication (or psychotropic like medication) and was at risk for adverse side effects. She took an antidepressant for her depression and her insomnia with interventions to review behaviors/interventions and alternate therapies attempted and their effectiveness per policy, and observe for adverse reactions to antidepressant therapy such as changes in behavior/mood/cognition. Review of the nurses notes, dated 06/30/22 at 8:48 P.M., revealed Resident #63 and another resident (Resident #93) were kicking each other by the dining room hallway. They were both separated and taken to their units. Resident #63 stated Resident #93 kicked her first, called her a (expletive), and she could not understand what else she was saying. Resident #63 then proceeded to kick Resident #93 back. Both residents started kicking each other. No skin issues were noted upon assessment. Vital signs were within normal limits and the physician and responsible parties were notified. 366201 Page 19 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/28/22 at 11:51 A.M. with Resident #63 revealed Resident #93 kicked her in her knee cap a few months ago. Resident #63 stated Resident #93 did it because she is mean and hateful. She stated staff witnessed the incident and saw/heard it. Review of the incident investigation form, dated 06/30/22, revealed Resident #63 and another resident (#93) started kicking each other. Both residents had a diagnoses of dementia. It stated there were no injuries noted to either resident and the residents were separated and returned back to their units. The residents returned to baseline after returning to their units. The physicians and families were updated. Interview on 09/29/22 at 10:06 A.M. with the DON confirmed the incident occurred on 06/30/22 between Resident #63 and Resident #93. The DON stated she was on vacation at the time and the Administrator was different than the current one. Interview on 09/29/22 at 2:44 P.M. with the DON confirmed there was no SRI completed for the incident between Resident #63 and Resident #93, and the incident was not reported to the state survey agency. Interview on 09/29/22 at 3:29 P.M. with the DON confirmed there were no additional investigation pieces for the incident between Resident #63 and Resident #93 besides the incident report. There were no witness statements, interviews, investigation, or follow up. Review of the facility policy and procedure titled, Abuse Prevention Program, dated March 2021, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also stated employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Administrator or his/her designee. The policy stated when an alleged or suspected case of mistreatment, neglect, exploitation, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately notify the state agency. The policy stated the facility will investigate the suspected incident, and it will consist of a minimum of a medical record review, interviews from the person reporting, interview with the witnesses, interview with the residents, interview with physicians, interview with other staff who had contact with the residents during the period of the alleged incident, and review all events leading up to the alleged incident. The policy stated the Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency. Based on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to timely investigate allegations or suspected incidents of abuse. This affected four (Residents #63, #72, #93, and former Resident #128) of six residents reviewed for abuse. The facility census was 128. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date on 03/09/20. Medical diagnoses included unspecified dementia, chronic obstructive pulmonary disease (COPD), unspecified psychosis, alcohol abuse, and alcoholic cirrhosis of liver. 366201 Page 20 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had mild cognitive impairment. Resident #72 required limited assistance from one staff to complete activities of daily living (ADLs). No behaviors were noted in the assessment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 had severely impaired cognition. Resident #72 displayed continuous delirium symptoms, verbal behaviors towards others, rejection of care, and wandering. Review of the progress note dated 04/23/22 at 9:03 P.M. revealed Resident #128 pushed Resident #72 to the floor in the left side sitting position. A head-to-toe assessment, neurological assessment, and pain assessment were completed. Resident #72 was alert and oriented with intermittent confusion, no skin discoloration or bruises were observed. Resident #72 denied any pain. Resident #72 was assisted off the floor to a standing position and was redirected back to his room. Resident #72's vital signs were within normal limits. Resident #72's guardian was notified via voicemail. The Director of Nursing (DON) and on-call physician were notified of the incident. 2. Review of the closed medical record for former Resident #128 revealed an admission date on 08/27/21 and discharge date on 09/26/22. Medical diagnoses included alcohol dependence, alcoholic hepatitis, dementia with behavioral disturbance, generalized anxiety disorder, borderline personality disorder, and metabolic encephalopathy. Review of the admission MDS assessment dated [DATE] revealed Resident #128 had intact cognition. Resident #128 required supervision to limited assistance from one staff to complete ADLs. No behaviors were noted in the assessment. Review of the nurse's notes revealed on 04/23/22, Resident #128 pushed Resident #72 to the floor. Resident #128 was unprovoked and intoxicated at the time of the incident. Review of the Physical Incident Report dated 04/23/22 at 7:04 P.M. revealed Resident #128 pushed Resident #72 when Resident #72 entered Resident #128's room. Resident #72 did not take any of Resident #128's belongings or provoke Resident #128. The residents were separated. Resident #128 stated, Get the (expletive) out of my room. I told him to stay the (expletive) out of my room. A head-to-toe assessment, neurological assessment and pain assessment were completed on Resident #72. Resident #128 was alert and oriented but appeared intoxicated at the time of the incident. Licensed Practical Nurse (LPN) #333 attempted to educate Resident #128 but the resident became aggressive both physically and verbally with staff and continued to use foul language, including (expletive) and (expletive) words. Every 15-minute checks were initiated. Certified Nurse Practitioner (CNP) #530 was notified. Review of the facility's Self-Reported Incidents (SRI's) for the last year revealed there was not a SRI opened related to the physical and verbal altercation between Resident #72 and Resident #128. Interview on 09/28/22 at 1:55 P.M. with the DON revealed she had not witnessed Resident #128 being physically aggressive toward any residents or staff but the resident was verbally aggressive. Resident #128 drank alcohol at the facility usually after hours. Resident #128 had been placed on 15-minute checks, was seen by psychiatric services, and received medication for alcohol abuse. The DON stated, that's just him. Interview on 09/28/22 at 2:13 P.M. with Medical Records (MR) #203 revealed she was not clinical but was familiar with Resident #128. MR #203 stated Resident #128 was easily agitated and became 366201 Page 21 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some verbally aggressive toward staff and other residents, especially when he was drinking alcohol. MR #203 stated she had witnessed Resident #128 engaged in verbal altercations during the day and had heard from other staff altercations also occurred at night. Interview via telephone on 09/28/22 at 2:30 P.M. with Nursing Home Administrator (NHA) #531 (previous Administrator) revealed he was familiar with Resident #128. NHA #531 confirmed Resident #128 had a history of alcohol abuse and would frequently leave the facility. Resident #128 was alert and oriented. Resident #128 had a physician order to allow him to consume one can of beer daily but he frequently drank more than that and brought outside alcohol into the facility. NHA #531 denied knowledge of Resident #128 being physically aggressive with any residents or staff but could be verbally aggressive. Interview on 09/28/22 at 5:27 P.M. with LPN #333 revealed Resident #128 was intoxicated frequently at the facility. LPN #333 stated the resident was not compliant with only drinking one beer daily per physician orders and frequently found alcohol in Resident #128's room including bottles of liquor and beer. LPN #333 stated Resident #128 was verbally aggressive when intoxicated. LPN #333 denied knowledge of any physical altercations that Resident #128 was involved in but confirmed he completed the incident report dated 04/23/22. Interview on 09/29/22 at 10:00 A.M. with the NHA confirmed an SRI was not opened, the incident was not reported to the state survey agency, and there was no further investigation following the physical altercation between Residents #72 and #128. 366201 Page 22 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of Pre-admission Screening and Resident Reviews (PASARRs), and review of facility policy, the facility failed to ensure an updated PASSAR was completed after a resident experienced a significant change or was diagnosed with a newly evident serious mental disorder. This affected three (Residents #7 #48, and #110) of six residents reviewed for PASARR screenings. The facility census was 128. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date on 09/15/20. Medical diagnoses included vascular dementia with behavioral disturbance (09/15/20), psychotic disorder (06/01/21), major depressive disorder (12/07/21), anxiety disorder (12/07/21), and post-traumatic stress disorder (PTSD) (12/21/15). Review of Resident #7's current physician orders dated September 2022 revealed Resident #7 had orders for the following psychotropic medications: Mirtazapine (antidepressant medication) 15 milligrams (mg) daily at bedtime for depression (07/21/22), Ziprasidone Hydrochloride (HCl) (antipsychotic medication) 20 mg twice daily for psychotic disorder with hallucinations (02/22/22), and Clonazepam (a medication in the class of medications called benzodiazepines) two mg twice daily for anxiety disorder (12/03/21). Review of the annual Minimum Data Set (MDS) assessment, dated 08/18/22, revealed Resident #7 had moderately impaired cognition. Resident #7 was administered daily antipsychotic, antianxiety, and antidepressant medications. Review of the most recent PASARR screening dated 09/25/20 for Resident #7 revealed the screening did not include the resident's diagnoses of vascular dementia with behavioral disturbance given to the resident on 09/15/20 or the diagnosis of PTSD given to Resident #7 on 12/21/15. The screening did not include any psychotropic medications utilized to treat Resident #7's mental health conditions. Review of the medical record for Resident #7 revealed there was not an updated PASARR completed when Resident #7 received additional mental health diagnoses including: psychotic disorder or anxiety disorder. Interview on 09/29/22 at 3:06 P.M. with Regional Nurse (RN) #420 confirmed the PASARR screening completed on 09/25/20 did not include all of Resident #7's mental health diagnoses. RN #420 also confirmed an updated PASARR was not completed when Resident #7 received additional mental health diagnoses. 2. Review of the medical record for Resident #48 revealed an admission date on 04/13/21. Medical diagnoses included bipolar disorder, major depressive disorder, vascular dementia with behavioral disturbance (02/04/22), psychotic disorder with hallucinations due to known physiological condition (02/04/22), and generalized anxiety disorder (02/04/22). Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had intact cognition. Resident #48 was administered daily antipsychotic and antidepressant medications. 366201 Page 23 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the significant change PASARR, dated 10/14/21, for Resident #48 revealed it only included Resident #48's diagnoses of major depressive disorder and bipolar disorder. Review of the medical record for Resident #48 revealed there was not another updated PASARR screening completed when Resident #48 received the following additional mental health disorders: psychotic disorder with hallucinations, generalized anxiety disorder, or vascular dementia with behavioral disturbance. Interview on 09/29/22 at 2:58 P.M. with Social Services (SS) #501 confirmed Resident #48's PASARR screening was not updated to include all of the resident's mental health diagnoses. 3. Review of the medical record for Resident #110 revealed an admission date of 08/29/20 and a readmission date on 03/05/21. Medical diagnoses included anxiety disorder (09/07/20), major depressive disorder (09/07/20), bipolar disorder (08/29/20), alcohol abuse (01/26/22), and unspecified psychosis (08/29/20). Review of the quarterly MDS assessment, dated 10/01/22, revealed Resident #110 had intact cognition. Review of Resident #110'S PASARR screening, dated 09/07/20, revealed it only included Resident #110's diagnoses of anxiety disorder and major depressive disorder. Review of Resident #110's medical record revealed there was not an updated PASARR completed for Resident #110 when the resident received additional mental health diagnoses including: unspecified psychosis and alcohol abuse. Interview on 09/29/22 at 2:58 P.M. with Social Services (SS) #501 confirmed Resident #110's PASARR screening was not updated to include all of the resident's mental health diagnoses. Review of the facility policy, Pre-admission Screening and Resident Review, revised 08/2020, revealed the policy stated, it is the policy of the facility to complete a Level One/Level Two assessment upon admission and as needed to ensure the specialized needs of residents with severe mental illness (SMI) or intellectual or developmental disabilities (IDD) are met. A Level One assessment is completed with any new mental health diagnoses, symptoms, psychiatric hospitalizations, and/or related medications. 366201 Page 24 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed timely. This affected one (Resident #41) of six residents reviewed for PASARR screenings. The facility census was 128. Residents Affected - Few Findings include: Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included schizoaffective disorder. Review of quarterly Minimum Data Set assessment, dated 09/13/22, revealed Resident #41 was cognitively intact. Review of Resident #41's medical record revealed there was not a PASARR completed upon admission. Interview with the Director of Nursing (DON) on 09/27/22 at 3:30 P.M. confirmed Resident #41 did not have a PASARR completed upon admission and a PASSAR should have been completed. Review of the policy entitled Pre-admission Screening and Resident Review dated 08/01/20 revealed the purpose of Pre-admission Screening and Resident Review (PASRR) is to identify the best services and location for residents and/or those considering admission to a Medicaid certified nursing home who also have a Serious Mental Illness (SMI) or an Intellectual or Developmental Disability (IDD). A PASRR is required before a person with a SMI or IDD is admitted to the facility. It is the policy of the facility to complete a Level 1/Level 2 Assessment upon admission and as needed to ensure the specialized needs of residents with SMI or IDD are met. 366201 Page 25 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and resident interview, the facility failed to get ensure residents who were dependent on staff assistance for activities of daily living were provided assistance with getting out of bed. This affected one (#37) out of four residents reviewed who were dependent on staff assistance for activities of daily living. The census was 128. Residents Affected - Few Findings include: Review of medical record for Resident #37 revealed an admission date of 01/12/21. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction, and dementia. Review of the Minimum Data Set assessment, dated 09/13/22, revealed Resident #37 was cognitively impaired. Resident #37 required extensive two-person physical assist with bed mobility, transfers, toilet use, bathing, and personal hygiene. Resident required extensive one-person physical assist for eating. Resident #37 used a wheelchair to ambulate in the facility. Resident #37 was able to use her voice to speak very softly, but most of the time pointed with hands, answered with a head shake, or voiced concerns with soft voice. Review of Resident #37's plan of care, dated 07/10/22, revealed Resident #37 was at risk for self-care deficit with an activity of daily living decline related to cerebral vascular accident. Interventions included encourage resident participation while performing activity of daily living, may have mobility bars if desired, preventative skin care as needed, report declines, shower per resident preference, staff to anticipate needs, and therapy to evaluate. Resident #37 was also at risk for falls related to injury and having a history of falls. Interventions included but were not limited to assist with transfers. Obsevation on 09/27/22 at 11:05 A.M. revealed Resident #37 was in bed and appeared unclean. Observation on 09/27/22 at 3:15 P.M. revealed Resident #37 was still in bed. Observation on 09/28/22 at 11:00 A.M. revealed Resident #37 was laying in her bed in her room. Interview on 09/28/22 at 11:35 A.M. with State Tested Nurse Aided (STNA) #372 revealed Resident #37 had been trying to smoke cigarettes and would try to get out of bed to smoke cigarettes. Interview on 09/28/22 at 1:00 P.M. with Resident #37 revealed she wanted to get out of bed and pointed to her specialized wheelchair. Observation on 09/28/22 at 3:00 P.M. revealed Resident #37 was laying in her bed. Observation on 09/29/22 at 11:00 A.M. revealed Resident #37 was laying in her bed in her room. Observation on 09/29/22 at 1:00 P.M. revealed Resident #37 was laying in her bed in her room. Interview on 09/29/22 at 3:40 P.M. with Resident #37 revealed she wanted to get out of bed. Interview on 09/29/22 at 4:00 P.M. with Physical Therapy Assistant (PTA) #243 revealed Resident #37 did not have a pole attachment ordered for her specialized wheelchair. PTA #243 stated Resident #37 366201 Page 26 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0677 Level of Harm - Minimal harm or potential for actual harm can get up anytime in her specialized wheelchair or any chair that was safe for the resident. If Resident #37 wanted to ambulate by propelling herself then she could use her wheelchair to do so. PTA #243 stated on 09/30/22, a company is going to come out and measure as well as order a pole that could be used on Resident #37's specialized wheelchair in order to allow her to take her tube feeding with her. PTA #243 stated it would not be a problem to get Resident #37 out of bed if she wished. Residents Affected - Few Interview on 09/29/22 at 4:15 P.M. with the Director of Nursing (DON) revealed she was unaware Resident #37 was asking to get out of bed the last three days. The DON stated she would fix it right away. Observation on 09/29/22 at 5:00 P.M. of Resident #37, Nurse Aide #341, and Nurse Aide #358 revealed they were using a mechanical lift to get Resident #37 out of bed per Resident #37's request. Resident #37 was transferred to a wheelchair. Interview on 10/03/22 at 1:16 P.M. with STNA #320 revealed she was not able to get Resident #37 out of bed in the morning on 10/02/22 because the facility was short staffed. STNA #320 stated she went to Resident #37 and asked her again on 10/02/22 at 2:00 P.M. however Resident #37 no longer wanted to get out of bed. Interview on 10/03/22 at 2:45 P.M. with Resident #37 revealed staff did not get her out of bed on 10/02/22. Resident #37 stated the facility was short staffed on 10/02/22. Resident #37 stated she had wanted to get up on 10/02/22. 366201 Page 27 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff and resident interview, review of a activity calendar, review of participation records, and policy review, the facility failed to ensure activities were provided to meet the needs/interests of the residents. This affected one (#41) of one resident reviewed for activities. The census was 128. Residents Affected - Few Findings include: Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, and diabetes. Review of the activity evaluation, dated 07/11/22, revealed it was somewhat important for Resident #41 to have books, newspaper, and magazines to read, to listen to music she liked, to be around animals, keep up with the news, do things with groups of people, and do favorite activities. It was very important to participate in religious services or practices. Review of the September 2022 activity calendar revealed church services were scheduled for 09/04/22 at 3:00 P.M. Review of the participation log, dated 09/04/22, revealed Resident #41's name was not on the list of residents who attended the church service. Review of the participation logs for one to one's from 09/09/22 through 09/28/22 revealed no staff had a one to one with Resident #41 between 09/09/22 and 09/28/22. Review of the quarterly Minimum Data Set assessment, dated 09/13/22, revealed Resident #41 was cognitively intact. Resident #41 required extensive two person assistance for bed mobility and required total dependence two person assistance for transfers. Interview with Resident #41 on 09/26/22 at 2:42 P.M. revealed she did not receive any one to one's from the activity staff. She stated she would like to go to church but has not been able too. She didn't know the facility had church on Sundays and did not know there was an activity calendar to choose what she would like to participate in. Observation during the interview revealed there was not an activity calendar in Resident #41's room. Interview with Activity Director (AD) #206 on 09/29/22 at 3:02 P.M. revealed church service was restarted on 09/04/22 for that Sunday only. She confirmed if the activity was on the weekends the staff would not get up the residents to come to activities because they were short staffed and the activity staff were not qualified to get the residents up. She stated Resident #41 was supposed to receive one to one's with staff and she had been telling her staff to do this, but it was not getting done and it was not documented either. She stated the previous Director of Nursing instructed her to not place activity calendars in the resident rooms and she did not know why. Review of policy titled Activity Programs, dated 07/01/18, revealed activity programs are designed to meet the needs of each resident are available every day. The activities program are scheduled seven days a week during the day and some evenings. The activity programs consist of individual, small and large groups activities that are designed to meet the needs and interests of each resident and include spiritual programming to meet the needs of the residents. Activity calendars will be given 366201 Page 28 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0679 individually to the residents who can access the activity board. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366201 Page 29 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

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** 2. Medical record review for Resident #56 revealed an admission date of 08/03/16. Medical diagnoses included multiple sclerosis, neurogenic bladder, and paraplegia. Residents Affected - Few Review of the care plan, dated 07/08/21, revealed Resident #56 was at risk for impaired skin integrity related to skin breakdown, impaired mobility and non-compliance with care at times. Interventions were to apply barrier cream/ointment after incontinence as needed. Review of the quarterly MDS assessment, dated 07/12/22, revealed Resident #56 was cognitively intact. Review of Resident #56's physician orders, dated 07/22/22, revealed an order to apply triad cream to right and left buttocks twice daily. Observation of a dressing change for Resident #56 on 09/28/22 at 3:33 P.M. revealed she had moisture associated skin damage (MASD) above her gluteal fold. Licensed Practical Nurse (LPN) #333 washed his hands, donned gloves, removed the calcium alginate from the MASD in the gluteal fold, washed the MASD with normal saline and dried it. LPN #333 proceeded to remove his gloves, wash his hands, don new gloves, then placed a calcium alginate square on the MASD in the gluteal fold, and placed a foam dressing on the MASD with a date on the dressing. Interview on 09/29/22 at 8:12 A.M. with LPN #389 and Registered Wound Nurse (RWN) #334 confirmed there was calcium alginate in Resident #56's gluteal fold and stated this was the wrong order. The interview further revealed triad cream should have been used. Interview with LPN #333 on 10/02/22 at 12:29 P.M. confirmed he applied the wrong treatment order on the MASD for Resident #56. Review of policy titled Skin Management, dated 10/01/19, revealed the treatment order would be obtained before the procedure. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure wound treatments were completed according to physician orders. This affected two (#9 and #56) of seven residents reviewed for wound treatments. The census was 128. Findings include: 1. Review of the medical record for Resident #9 revealed an admission on [DATE]. Diagnoses included cellulitis of the right lower limb, erythema intertrigo, non-pressure chronic ulcer of unspecified part of lower leg with severity, lymphedema, and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required supervision and setup help for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Review of the plan of care, dated 02/08/22, revealed Resident #9 was at risk for refusing treatments and medications at times. Interventions included administer medications as ordered, allow resident 366201 Page 30 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to vent feelings, approach resident in a calm and friendly manor, assess resident's needs, and give the resident as many choices. Review of Resident #9's physician order dated 09/28/22 at 7:17 A.M. revealed an order to cleanse with wound cleanser, apply silver alginate to wound bed, cover with abdominal dressing, and wrap with kerlix every day for wounds to the right anterior ankle, left anterior ankle, and right lateral ankle ulcers. The order further revealed to apply ace wraps every day shift. Observation on 09/29/22 at 2:50 P.M. with Licensed Practical Nurse (LPN) #374 revealed LPN #374 took off Resident #9's wound dressing wraps to the bilateral legs and preceded to clean one leg at a time. Resident #9's left leg had four wound areas that covered in silver alginate while Resident #9's right leg had three wound areas covered in silver alginate. Interview on 09/29/22 at 2:58 P.M. with LPN #374 revealed there was additional silver alginate on Resident #9's bilateral legs, that was not apart of the current physician orders. LPN #374 stated there was no date or name on either of the dressings that were removed from Resident #9's legs. Observation on 09/29/22 at 3:00 P.M. of LPN #374 who performed the wound treatment to Resident #9's bilateral legs revealed LPN #374 did not complete the wound treatment as ordered by the physician. LPN #374 applied silver alginate to the wound beds but did not use an abdominal dressing, before wrapping the wounds with kerlix. Interview on 09/29/22 at 3:10 P.M. with LPN #374 revealed she did not complete the treatment correctly for Resident #9's bilateral legs. 366201 Page 31 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff and resident interview and policy review, the facility failed to ensure pressure ulcer interventions and treatments were initiated timely. This affected two residents (#29 and #106) out of six residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The census was 128. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 04/06/15 and the diagnoses of chronic obstructive pulmonary disease (COPD), cerebral infarction, and spastic hemiplegia. Review of the Minimum Data Set (MDS) assessment, dated 08/28/22, revealed Resident #29 required extensive two staff assistance for bed mobility, personal hygiene and toilet use. The assessment indicated Resident #29 had two stage four pressure ulcers. Review of the care plan, dated 08/28/18, revealed Resident #29 was at risk for skin breakdown related to decreased mobility, weakness, and moderate protein calorie malnutrition with interventions to provide treatments as ordered and monitor for skin breakdown. The care plan, dated 06/11/21 and updated 03/17/21, revealed Resident #29 had the potential for nutritional risk related to diagnoses including skin impairment with interventions to provide supplements as ordered (initiated on 03/24/22). Review of the Braden pressure ulcer risk assessments, dated 10/15/21 through 09/17/22, revealed Resident #29 was at moderate to high risk for pressure ulcers. Review of the wound documentation, dated 01/17/22, revealed Resident #29 was noted with a new wound to her left middle finger measuring 1.15 centimeters (cm) by 0.76 cm with 100% granulation tissue. There were new orders to cleanse the wound with normal saline daily and apply xeroform. At the time of the survey, the wound was still present, healing, and being treated. Review of the nutrition/dietary note, dated 03/24/22, revealed it was noted Resident #29 had a pressure injury reported to the left middle finger and a treatment was in place. A new recommendation was to begin active liquid protein 30 milliliters (ml) once a day for added protein support. Review of the Resident #29's nurses notes, dated 04/18/22, revealed a new order was received to add active liquid protein 30 ml daily per the dietitian. The physician was notified and was in agreement. Review of Resident #29's physician orders revealed on 04/19/22, Resident #29 was ordered active liquid protein once daily. Interview on 09/29/22 at 11:57 A.M. with Dietitian #207 confirmed the facility did not initiate the active liquid protein supplement timely. 2. Review of the medical record for Resident #106 revealed an admission date of 08/29/22 and the diagnoses of diabetes type two, COPD, end stage renal disease, dependence on renal dialysis, and heart failure. 366201 Page 32 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medicare Five Day MDS assessment, dated 09/04/22, revealed Resident #106 was at risk for pressure, but she had no pressure ulcers. Review of the care plan, dated 08/29/22, revealed Resident #106 had impaired skin integrity with interventions to assess and document skin conditions, notify the physician of signs of infection, and complete wound treatments as ordered. Review of the Braden Scale for Predicting Pressure Ulcer Risk, dated 08/29/22, revealed Resident #106 was at risk for pressure ulcers. Review of the physician orders for Resident #106 revealed on 09/28/22, the physician ordered triad cream to right inner thigh twice daily for wound. Prior to 09/28/22, Resident #106 was only ordered triad cream to buttocks twice daily, house barrier cream to buttocks, coccyx, and periarea every shift with incontinent episodes and reapply as needed. There were no orders for fungal cream to be applied to wounds and no order for a treatment to the wound to Resident #106's thigh. Review of the skin assessment, dated 09/25/22, revealed Resident #106 only had a surgical incision, but no other open areas. Review of the skin assessment, dated 09/27/22, revealed Resident #106 had an open area to her groin that was not new. Review of the nurses note, dated 09/28/22 at 6:31 P.M., revealed during care, the nurse noted an open area to Resident #106's right inner thigh, red in color in the middle with pink skin surrounding, and no drainage noted. The area measured 10 centimeters (cm) by 0.7 cm by 0.1 cm. Resident #106 stated sometimes the brief is too tight and it scratches her skin. The resident was assessed by the nurse, the unit manager was updated, the physician was updated, the family was updated, a new treatment was initiated for triad cream twice daily, and the STNA's were inserviced on the proper way to apply briefs. Interview on 09/27/22 at 8:51 A.M. with Resident #106 revealed staff sometimes apply cream to her bottom but she had an open area and no one looked at it in a while besides the aides. Interview on 09/29/22 at 8:46 A.M. with Resident #106 revealed staff had not been putting any sort of treatment on the wound to her right inner thigh and the wound was caused because the briefs were too tight and the staff wouldn't move her thigh skin out of the way of the brief, the briefs had been tight like that since she was admitted , but she wasn't sure when the wound began. Observation on 09/28/22 at 3:30 P.M. of Resident #106's skin with Licensed Practical Nurse (LPN) #356 and State Tested Nurse Assistant (STNA) #372 revealed the front of Resident #106's right thigh had an obvious thin open wound shaped as a long, slightly curved line. The area was beefy red and approximately six to eight inches long. Interview and observation on 09/28/22 at 3:30 P.M. with STNA #372 revealed she noticed the open wound to Resident #106's right thigh last week and notified LPN #319. STNA #372 stated she had been putting antifungal cream on the wound and she applied the cream to the open wound. Interview on 09/28/22 at 3:30 P.M. with LPN #356 revealed she had been gone for an extended time and this day was her first day back. She stated before she left, she hadn't noticed the wound to 366201 Page 33 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #106's thigh, but also stated she was going to notify the physician and make a risk report if the other nurse had not completed one. Interview on 09/29/22 at 8:52 A.M. with LPN #356 revealed she completed a risk assessment, started treatments for the residents wound and initiated an STNA inservice. She stated there was no risk assessment completed that she was aware of and she further confirmed STNA #372 put fungal cream on the wound. LPN #356 stated she looked into Resident #106's treatments and noticed that the aide had used the wrong cream, so LPN #356 washed it off and received the order for the triad cream. Review of the facility policy titled, Skin Management, dated October 2019, revealed any skin alterations noted by direct care givers during daily care must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open area, redness, skin tears, blisters and rashes. The nurse is responsible for assessing any and all skin alterations as reported by the direct caregivers on the shift reported. Residents at risk for skin breakdown will have appropriate prevention interventions in place. It also stated alterations in skin integrity will be reported to the physician and responsible party and a treatment order will be obtained, and all alterations in skin will be documented in the medical record. 366201 Page 34 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

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. Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided appropriate supervision while smoking. This affected one (#49) out of three residents reviewed for accidents. Additionally, the facility failed to provide safe smoking areas. This had the potential to affect all 36 residents (#1, #5, #12, #13, #14, #16, #19, #20, #23, #28, #30, #31, #33, #34, #37, #45, #49, #52, #55, #61, #62, #64, #71, #80, #81, #83, #86, #93, #98, #101, #104, #122, #126, #128, #129, and #130) identified by the facility who smoke. The census was 128. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 01/11/22 and diagnoses including chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis, congestive heart failure (CHF), and nicotine dependence. Review of the quarterly Minimum Data Set assessment, dated 07/05/22, revealed Resident #49 had impaired cognition. Review of the nurses notes, dated 07/16/22 at 11:51 A.M., revealed Resident #49 was found in the smoking doorway smoking inside the building. The note revealed it was raining and Resident #49 threw a cigarette butt out the door onto the floor. Resident #49 was educated he would now be a supervised smoker and would have to go outside with staff to smoke. The Director of Nursing (DON) was notified. Review of Resident #49's care plan, dated 04/29/22, revealed he was an unsupervised smoker and on 07/22/22 the care plan was updated revealing Resident #49 was a supervised smoker with interventions to observe clothing and skin for cigarette burns, smoking material to be kept with facility staff, and complete smoking assessment quarterly and as needed. Review of the smoking review, dated 07/16/22, revealed on this day, Resident #49 was found in the doorway smoking inside the building. It was raining and the resident threw a cigarette butt out the door onto the floor. Resident #49 was educated he would now be a supervised smoker and would have to go outside with staff to smoke. Interview on 09/26/22 at 1:08 P.M. with State Tested Nurse Assistant (STNA) #320 and Licensed Practical Nurse (LPN) #311 revealed both staff stated Resident #49 was not a supervised smoker, and that he was currently independently smoking outside. Observation on 09/26/22 at 1:09 P.M. revealed Resident #49 outside lighting a cigarette, then smoking, with no staff present. Interview and observation on 09/26/22 at 1:11 P.M. with STNA #320 confirmed there were no staff outside to supervise Resident #49 while he was smoking. She also confirmed his most recent evaluation from 07/22/22 stated Resident #49 was to be a supervised smoker. STNA #320 stated she was unaware that Resident #49 was to be supervised. Review of the smoking review, dated 09/27/22, revealed Resident #49 had been without incident since 366201 Page 35 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0689 Level of Harm - Minimal harm or potential for actual harm 07/16/22 and was following proper safety and handling. Resident #49 was removed from supervised smoking and was an independent smoker. 2. Observation on 09/28/22 at approximately 2:43 P.M. revealed there were no ash trays in the memory care smoking area. Residents Affected - Some Observation on 09/29/22 at 3:34 P.M. revealed there were numerous discarded cigarette butts in the grass near the staff smoking area. In addition, the metal ash can in this area was completely full of combustible trash items. Interview with the Maintenance Director at the time of discovery verified the above findings. Review of the facility policy titled, Smoking, dated June 2022, revealed residents that meet the criteria to smoke independently will be allowed to do so within the guidelines. It also stated the area must be free of combustible materials, with suitable noncombustible ashtrays. The policy revealed residents that require supervision to smoke will be supervised while actively smoking and their materials are kept and distributed by staff, not residents. Operation of lighters and matches will be done under direct supervision. 366201 Page 36 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure nutritional supplements were provided as ordered and weights were obtained as ordered. This affected one (#58) of four residents reviewed for nutrition. The facility identified there were 19 residents with unplanned significant weight loss. The census was 128. Residents Affected - Few Findings include: Medical record review for Resident #58 revealed an admission date of 04/01/22. Medical diagnoses included diabetes, renal insufficiency, and non-Alzheimer's dementia. Review of Resident #58's weights revealed Resident #58 weighed 174.8 pounds on 04/01/22. Further review of the weights revealed Resident #58 weighed 151.0 pounds on 09/26/22. Review of quarterly Minimum Data Set, dated [DATE], revealed Resident #58 was severely cognitively impaired. Resident #58 required supervision with eating. Review of Resident #58's care plan dated 07/21/22 revealed Resident #58 was at risk for malnutrition related chronic disease with noted obesity status. Interventions were to obtain weight as ordered, and monitor and provide supplements as ordered. Review of Resident #58's physician orders dated 07/21/22 revealed an order for magic cup (nutritional supplement) with all meals for weight management. Review of the progress note from Dietitian #207, dated 07/21/22, revealed Resident #58's weight history was 162.8 pounds on 07/20/22, 166 pounds on 07/07/22, 178 pounds on 06/02/22 and 160.2 pounds on 04/21/22. It was noted that currently Resident #58 was triggering for a 15.8 pound or 8.8 percent significant weight loss since 06/02/22. The resident had been having weight fluctuations between 160 pounds and 180 pounds since admission to facility. Resident #58's order for magic cup was changed to three times a day with meals. Dietitian #207 was to monitor Resident #58 as needed. Review of Resident #58's physician orders dated 07/25/22 revealed an order for weekly weights. Review of meal intake records from 09/04/22 through 10/04/22 revealed Resident #58 fluctuated from 50 to 75 percent and 75 to 100 percent of meals. Review of Dietitian #207's note dated 09/22/22 for Resident #58 revealed Resident #58's weight history was 150.4 pounds on 09/02/22, 162.8 pounds on 07/20/22 and 178 pounds on 06/02/22. The resident was currently triggering for a 27.6 pound or 15.5 percent significant weight loss in three months. A reweigh was requested due to not being at the recent usual body weight (UBW). The reweigh was not completed until 09/26/22 and was 151 pounds. The resident was on a regular/dysphagia advanced texture/thin diet with intakes of 51 to 100 percent for most meals. It was noted the magic cup was accepted and to monitor as needed. Observation of Resident #58's meal on 10/03/22 at 8:24 A.M. revealed she had a regular/dysphagia advanced texture/thin diet for breakfast. The ticket revealed pureed toast, margarine, syrup, ground sausage patty, bacon gravy, pureed oatmeal cereal, milk, and orange juice. Resident #58 did not have 366201 Page 37 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0692 a magic cup on the ticket order or on her tray. Level of Harm - Minimal harm or potential for actual harm Observation of the lunch tray and ticket for Resident #58's meal on 10/03/22 at 12:04 P.M. revealed she had a regular/dysphagia advanced texture/thin diet but there was not a magic cup on the tray or the ticket. Residents Affected - Few Interview with Dietary Manager (DM) #205 on 10/03/22 at 12:09 P.M. revealed if a resident was ordered a magic cup then it would generate onto the meal ticket. He stated he didn't know Resident #58 was supposed to get a magic cup with her meals. Review of documentation on 10/03/22 at 12:11 P.M. from the Licensed Practical Nurse (LPN) #373 revealed Resident #58's magic cup was documented as given and 100 percent was consumed for breakfast and lunch. Interview with the Registered Nurse (RN) #504 on 10/03/22 at 12:13 P.M. verified Resident #58's orders and verified the magic cup wasn't on the meal tickets and the weights were not documented weekly. Interview with Licensed Practical Nurse (LPN) #373 on 10/03/22 at 12:22 P.M. revealed she documented on the Treatment Administration Record (TAR) the magic cup was administered at breakfast and lunch, and documented Resident #58 consumed 100 percent. She stated this was done in error. She confirmed at breakfast she was passing medications down the hall while the residents ate. She confirmed she was passing medications at lunch time too and documented 100% for the lunch time Magic Cup however the resident wasn't finished eating lunch at the time of the interview. Interview with State Tested Nursing Aide (STNA) #321 on 10/03/22 at 12:24 P.M. confirmed Resident #58 did not receive a magic cup on her tray for breakfast and she didn't assist the resident with a magic cup at breakfast either. Interview with the Dietary Tech (DT) #207 on 10/03/22 at 2:29 P.M. revealed she couldn't figure out why the resident continued to lose weight since she was eating well, unless it was the end stage Alzheimer dementia process. She confirmed she was aware Resident #58's weights were not completed weekly even after multiple attempts with nursing to obtain a weekly weight. She didn't know a Magic Cup had been documented and not given. She said the supplements could make an impact on the resident's weight loss, but stated the resident continued to eat well. She further revealed the supplements needed to be given with every meal. Review of policy titled Weight Process, undated, revealed weekly weights will be recorded in the electronic charting. Weekly weights should be measured on the same day of each week. Review of policy titled Nutritional Management, dated 11/01/17, revealed the facility will provide care and service to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. 366201 Page 38 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents who utilized oxygen had a physician order for oxygen. Additionally, the facility failed to ensure oxygen tubing was dated. This affected two (#60 and #86) of two residents reviewed for respiratory care. The facility identified 20 residents who received oxygen therapy. The census was 128. Residents Affected - Few Findings include: 1. Medical record review for Resident #86 revealed an admission date of 04/19/22. Medical diagnoses included chronic obstructive pulmonary disease (COPD) and bipolar disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact. Review of Resident #86's physician orders since 04/19/22 revealed there was no order for oxygen. Observation of Resident #86 on 09/26/22 at 1:27 P.M. revealed she used oxygen and her tubing was not dated. Observation on 09/27/22 at 2:28 P.M. revealed Resident #86's oxygen tubing was not dated. Interview with Licensed Practical Nurse (LPN) #333 on 09/27/22 at 2:28 P.M. revealed on Sundays the oxygen tubing would be changed, dated, and documented in the record. He confirmed Resident #86 had oxygen and the oxygen tubing wasn't dated. Interview with the Director of Nursing (DON) on 09/27/22 at 3:00 P.M. confirmed Resident #86 did not have an order for oxygen and she would call the physician to obtain the order. 2. Medical record review for Resident #60 revealed an admission date of 03/23/22. Medical diagnoses included interstitial pulmonary disease, COPD, respiratory failure, and pulmonary hypertension. Review of the quarterly MDS assessment, dated 07/14/22, revealed Resident #60 was cognitively intact. She was coded for oxygen. Review of Resident #60's physician orders since 03/23/22 revealed she did not have an order for oxygen. Observation on 09/27/22 at 11:35 A.M. revealed Resident #60 had oxygen on per nasal cannula and the tubing was not dated. Observation on 09/27/22 at 2:28 P.M. revealed Resident #60's oxygen tubing was not dated. Interview with LPN #333 on 09/27/22 at 2:28 P.M. revealed on Sundays the oxygen tubing would be changed, dated, and documented in the record. He confirmed Resident #60 had oxygen and the oxygen tubing wasn't dated. Interview with the Regional Nurse (RN) #420 on 10/04/22 at 10:53 A.M. confirmed Resident #60 did 366201 Page 39 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0695 not have an order for oxygen. Level of Harm - Minimal harm or potential for actual harm Review of policy titled Oxygen Administration, dated 10/01/10, revealed the purpose of the policy was to provide guidelines for safe oxygen administration. In preparation for applying oxygen there must be a physician's order. Residents Affected - Few 366201 Page 40 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents received appropriate dialysis management services. This affected two residents (#105 and #106) out of two residents reviewed for dialysis. The facility identified 11 residents who received dialysis services. The census was 128. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #106 revealed an admission date of 08/29/22 and the diagnoses of diabetes type two, chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), dependence on renal dialysis, and heart failure (HF). Review of the care plan, dated 10/03/22, revealed Resident #106 required hemodialysis due to ESRD and was to receive in house dialysis with intervenitons to assess bruit and thrill every shift, do not draw blood or take blood pressure in arm with graft, and administer medications as ordered. Prior to 10/03/22, there were no care planned interventions to address Resident #106's dialysis services. Review of Resident #106's physician orders new orders were writtten on 10/03/22 for inhouse hemodialysis three times per week (Monday, Wednesday, and Friday), no needle sticks/blood draws or blood pressure in the right arm, and check fistula every shift for bruit and thrill, swelling, pain, change in temperature and/or bleeding. Prior to 10/03/22 there were no physician orders to address Resident #106's dialysis services. Interview on 09/27/22 at 8:47 A.M. with Resident #106 revealed her dialysis fistula was on her right side and no staff touch that arm. Interview on 10/03/22 at 1:25 P.M. with the Director of Nursing (DON) revealed staff should be documenting and monitoring dialysis residents bruit and thrill daily, and there should be an order for it. Interview on 10/03/22 at 1:54 P.M. with the DON confirmed Resident #106 had no orders or care plans for the monitoring of her dialysis/dialysis site. 2. Review of the medical record for Resident #105 revealed an admission date of 08/29/22. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, and renal dialysis dependent. Review of the medical record for Resident #105 revealed Resident #105 received dialysis at the facility every Monday, Wednesday, and Friday. Further review of the medical record for Resident #105 revealed there were no orders to monitor Resident #105's dialysis site. Interview on 10/03/22 at 4:41 P.M. with Regional Nurse #420 revealed there was no dialysis order to monitor for signs and symptoms of bleeding or to monitor Resident #105's right chest tunneled catheter. Regional Nurse #420 stated that the left AV shunt to Resident #105 arm had never worked per Resident #105. Interview on 10/03/22 at 5:00 P.M. with Resident #105 revealed she had a port in her upper right chest. Resident #105 stated dialysis monitors the site, but she did not think the facility had been 366201 Page 41 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0698 monitoring the site. Level of Harm - Minimal harm or potential for actual harm Observation on 10/03/22 at 5:00 P.M. of Resident #105's port revealed the dressing was clean, intact, and no bleeding. Resident #105's port was a double lumen and was intact and capped. Residents Affected - Few Review of the facility policy and procedure titled, Dialysis Care, dated July 2020, revealed the facility will assure that each resident that requires dialysis services, receives such services that are consistent with the professional standards, including continued assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at an off-site dialysis center, assessment of the resident before, during, and after dialysis treatments, and physician orders will be received at time of admission specific to the resident including, site access care, current schedule, exchanges (if applicable) and any orders related to the resident's specific dialysis needs. 366201 Page 42 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on medical record review, staff and resident interview, review of the daily staffing sheet and time punches, review of the activity calendar, review of participation logs, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the residents needs. This affected one (#41) of one reviewed for activities and had the potential to affect all 45 residents on the 200 hall (#3, #7, #8, #12, #17, #18, #19, #22, #23, #26, #28, #32, #34, #40, #41, #42, #46, #48, #50, #56, #57, #60, #68, #74, #79, #81, #85, #86, #87, #88, #93, #94, #96, #97, #100, #109, #110, #114, #116, #118, #121, #122, #127, #129, and #382). This also affected one (#37) of five residents reviewed for activities of daily living and had the potential to affect all 21 residents who resided on the 300 hall (#1, #6, #9, #14, #25, #31, #36, #53, #55, #61, #62, #65, #70, #84, #99, #104, #105, #107, #112, #119, and #125). The census was 128. Findings include: 1. Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, and diabetes. Review of the daily staffing sheet for 09/04/22 revealed there were three State Tested Nursing Aides (STNA's) scheduled for the 200 hall on day shift but one STNA was a no call no show, and STNA #324 and STNA #320 worked on the 200 hall. Review of punch times for STNA #324 and STNA #320 revealed they each worked 11.5 hours on 09/04/22. Review of the September 2022 activity calendar revealed on 09/04/22 at 3:00 P.M., there were church services offered. Review of the activity participation log, dated 09/04/22, revealed Resident #41's name was not on the list of residents who attended the church service. Review of quarterly Minimum Data Set assessment, dated 09/13/22, revealed Resident #41 was cognitively intact. Resident #41 required extensive assistance for bed mobility and toilet use, and was total dependence for transfers, all with a two-person assistance. Interview with Resident #41 on 09/26/22 at 2:42 P.M. revealed she would like to go to church but had not been able too. Resident #41 didn't know the facility had church on Sundays and didn't know there was an activity calendar to choose what activities she would like to participate in. Observation at time of the interview revealed there wasn't an activity calendar in Resident #41's room. Interview with Activity Director (AD) #206 on 09/29/22 at 3:02 P.M. revealed church service was restarted on 09/04/22 for that Sunday only. She revealed if the activity was on the weekends then nursing staff wouldn't get the residents up to come to activities because they were short staffed and the activity staff were not qualified to get the residents up. Interview with STNA #320 on 10/03/22 at 1:06 P.M. revealed she worked on 09/04/22 and there were only two STNA's on the 200 hall taking care of 23 residents each. She said they usually have three STNA's but one calls off every weekend she was supposed to work which leaves them short staffed every weekend. She said only the ambulatory residents would be able to go to activities. There was activity staff in the facility on 09/04/22 but they don't get the residents up for activities. 366201 Page 43 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with STNA #324 on 10/03/22 at 1:51 P.M. revealed she worked on 200 hall on 09/04/22 and someone called off which caused them to be short staffed. She said she was taking care of 23 residents on that day and she couldn't find another aide to get Resident #41 up for the church service activity. 2. Review of medical record for Resident #37 revealed an admission date of 01/12/21. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction, and dementia. Review of the Minimum Data Set assessment, dated 09/13/22, revealed Resident #37 was cognitively impaired. Resident #37 required extensive two-person physical assist with bed mobility, transfers, toilet use, bathing, and personal hygiene. Resident required extensive one-person physical assist for eating. Resident #37 used a wheelchair to ambulate in the facility. Resident #37 was able to use her voice to speak very softly, but most of the time pointed with hands, answered with a head shake, or voiced concerns with soft voice. Review of Resident #37's plan of care, dated 07/10/22, revealed Resident #37 was at risk for self-care deficit with an activity of daily living decline related to cerebral vascular accident. Interventions included encourage resident participation while performing activity of daily living, may have mobility bars if desired, preventative skin care as needed, report declines, shower per resident preference, staff to anticipate needs, and therapy to evaluate. Resident #37 was also at risk for falls related to injury and having a history of falls. Interventions included but were not limited to assist with transfers. Observation on 09/27/22 at 11:05 A.M. revealed Resident #37 was in bed and appeared unclean. Observation on 09/27/22 at 3:15 P.M. revealed Resident #37 was still in bed. Observation on 09/28/22 at 11:00 A.M. revealed Resident #37 was laying in her bed in her room. Interview on 09/28/22 at 1:00 P.M. with Resident #37 revealed she wanted to get out of bed and pointed to her specialized wheelchair. Observation on 09/28/22 at 3:00 P.M. revealed Resident #37 was laying in her bed. Observation on 09/29/22 at 11:00 A.M. revealed Resident #37 was laying in her bed in her room. Observation on 09/29/22 at 1:00 P.M. revealed Resident #37 was laying in her bed in her room. The 300 hall had one nurse and two nurse aides on the floor. Interview on 09/29/22 at 3:40 P.M. with Resident #37 revealed she wanted to get out of bed. Interview on 09/29/22 at 4:00 P.M. with Physical Therapy Assistant (PTA) #243 revealed Resident #37 could get up anytime in her specialized wheelchair or any chair that was safe for the resident. If Resident #37 wanted to ambulate by propelling herself then she could use her wheelchair to do so. PTA #243 stated it would not be a problem to get Resident #37 out of bed if she wished. Interview on 09/29/22 at 4:15 P.M. with the Director of Nursing (DON) revealed she was unaware Resident #37 was asking to get out of bed the last three days. The DON stated she would fix it right away. 366201 Page 44 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/03/22 at 1:16 P.M. with State Tested Nurse Aide (STNA) #320 revealed she was not able to get Resident #37 out of bed in the morning on 10/02/22 because the facility was short staffed. STNA #320 stated she went to Resident #37 and asked her again on 10/02/22 at 2:00 P.M. however Resident #37 no longer wanted to get out of bed. Interview on 10/03/22 at 2:45 P.M. with Resident #37 revealed staff did not get her out of bed on 10/02/22. Resident #37 stated the facility was short staffed on 10/02/22. Resident #37 stated she had wanted to get up on 10/02/22. Review of the policy titled Staffing, dated 10/01/17, revealed the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The policy further revealed licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services, staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met, direct care staffing information per day (including agency and contract staff) is submitted to the Centers for Medicare/Medicaid Services (CMS) payroll-based journal system on the schedule specified by CMS, but no less than once a quarter, and inquiries or concerns relative to the facility's staffing should be directed to the Administrator or his/her designee. This deficiency substantiates Master Complaint Number OH00136409 and Complaint Number OH00136344. 366201 Page 45 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (%). Out of 29 opportunities, three errors were observed which equaled an error rate of 10.34%. This affected one (Resident #48) out of three residents observed during medication administration. The census was 128. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 04/13/22 and the diagnoses of acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set assessment, dated 07/05/22, revealed Resident #48 had the diagnoses of respiratory failure. Review of Resident #48's care plan, dated 10/03/22, revealed he was at risk for respiratory distress related to other acute respiratory failure with hypoxia with interventions to administer medications as ordered. Review of Resident #48's physician orders revealed orders for Artificial Tears Solution 0.5-0.6% (Polyvinyl Alcohol-Povidone) with instructions to instill two drops in both eyes four times a day for dry eyes (due at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.), Brimonidine Tartrate 0.2% solution with instructions to instill one drop in both eyes two times a day for glaucoma (due at 9:00 A.M. and 9:00 P.M.), and Ipratropium Bromide HFA (bronchodilator) aerosol solution 17 micrograms per actuation (mcg/act) with instructions to give two puffs orally every four hours for shortness of breath (due at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Observation on 09/28/22 at 10:04 A.M., revealed Licensed Practical Nurse (LPN) #333 administered Resident #48's Brimonide eye drops, at 10:13 A.M. he administered Resident #48's Ipratopium Bromide HFA aerosol solution, and at 10:27 A.M. he administered Resident #48's Artificial Tear eye drops. All of the medications were administered late. Interview on 09/28/22 at 10:30 A.M., with LPN #333 confirmed Resident #48's medications were given late. Review of the facility policy titled, Administering Medications, dated April 2019, revealed medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effects of medications. The policy stated medications are administered in accordance with physician ordered including any required time frame and medications are administered within one hour of their prescribed times, unless otherwise specified. 366201 Page 46 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 09/28/22 at 2:05 P.M. of the 100 hall medication storage room with Licensed Practical Nurse (LPN) #356 revealed a box with eight vials of sterile water/sterile vaccine diluent with live virus that expired on 02/06/22 and a bottle of Magnesium 500 milligram (mg) that expired December 2021. Interview on 09/28/22 at 2:05 P.M. with LPN #356 confirmed the expired medications in the 100 hall medication storage room. 4. Observation on 10/03/22 at 11:20 A.M. of the Ivy Hall Long Cart with LPN #383 revealed a loose pill identified as Guafenesin 600 milligram (mg) in the cart. Interview on 10/03/22 at 11:20 A.M. with LPN #383 confirmed the loose medication in the cart. 5. Observation on 10/03/22 at 11:37 A.M. of the 100 hall medication storage room with LPN #383 revealed two [NAME] jack string cheese packages in the medication refrigerator located in the medication storage room. Interview on 10/03/22 at 11:37 A.M. with LPN #383 confirmed the observation and confirmed food should not be kept in the medication storage room refrigerator with the medications. 6. Observation on 10/03/22 at 11:40 A.M. of the Omnicell Medication room on the 200 hall with LPN #383 revealed two bottles of expired ear wax removal drops, one expired on February 2021 and the other expired on May 2021. There were also two expired Narcan four milligram (mg) packs of two (to equal four total doses), which expired Mach 2021. Interview on 10/03/22 at 11:40 A.M. with LPN #383 confirmed the expired medications. 7. Review of the medical record for Resident #55 revealed an admission date of 05/12/21 and the diagnoses of hemiplegia and hemiparesis, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). Review of Resident #55's physician orders revealed orders for Ventolin (bronchodilator) 90 micrograms per actuation (mcg/act) with instructions to give two puffs by mouth every six hours as needed for COPD (initiated 05/17/21). Review of the medical record for Resident #61 revealed an admission date of 02/17/21 and the diagnosis of COPD. Review of Resident #61's physician orders revealed orders for Ventolin 90 mcg/act with instructions to give two puffs by mouth every six hours as needed for COPD (initiated 05/03/21) and Albuterol Sulfate (bronchodilator) HFA Aerosol Solution 108 (90 base) mcg/act with instructions to give two puffs by mouth every six hours as needed for COPD (initiated 02/17/21). Observation on 10/03/22 at 11:53 A.M. of the 300 hall medication cart with LPN #312 revealed loose medications identified as Lamotrigine (anticonvulsant) 100 milligram (mg) tablet, two Atorvastatin 366201 Page 47 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0761 Level of Harm - Minimal harm or potential for actual harm (statin) 10 mg tablets, Lasix (diuretic) 20 mg tablet, Zoloft (antidepressant) 50 mg, Zoloft 25 mg, Ibuprofen 400 mg, and a half tablet of Haldol (antipsychotic) 10 mg. In addition, there were also multiple expired medications including: Ventolin 90 mcg/act expired on July 2022 for Resident #55, two Ventolin 90 mcg/act one expired on May 2022 and March 2022 for Resident #61, and Albuterol 90 mcg/act expired in July 2022 for Resident #61. Residents Affected - Some Interview on 10/03/22 at 11:53 A.M. with LPN #312 confirmed the loose medications and the expired medications in the cart. 8. Observation on 10/03/22 at 12:17 P.M. of the 200 hall short medication cart with LPN #395 revealed multiple loose medications including a white round pill with no identifiers on it (unable to be identified), Metoprolol (beta blocker) 25 milligram (mg) and Naltrexone (opiate antagonist) HCl 50 mg. Interview on 10/03/22 at 12:17 P.M. with LPN #395 confirmed the loose medications. Review of the facility policy titled, Storage of Medications, dated April 2019, revealed drugs and biological's are stored in the packaging, containers or other dispensing systems in which they are received. It also stated discontinued and outdated drugs or biological's are returned to the dispensing pharmacy or destroyed. Furthermore, the policy revealed medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location and medications are stored separately from food and are labeled accordingly. Based on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to properly store and label medication as well as ensure medication was not expired. This affected two (#9 and #105) residents and had the potential to affect six residents (#2, #10, #13, #95, #112, and #285) with medications stored in the 100 hall medication storage room refrigerator, four residents (#18, #46, #81, and #85) who received medication from the 200 Short Hall medication cart, and 11 residents (#9, #25, #31, #53, #55, #61, #66, #70, #99, #112, and #119) who received medications from the 300 hall medication cart. The facility census was 128. Findings include: 1. Review of the medical record for Resident #105 revealed an admission date of 08/29/22. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, and renal dialysis dependent. Review of the Minimum Data Set (MDS) Medicare five day assessment revealed Resident #105 was cognitively intact. Review of the physician order, dated 09/06/22, revealed Resident #105 had an order for Lanthanum Carbonate 500 mg chewable to be taken with every meal for dialysis. Observation on 09/26/22 at 11:40 A.M. revealed Resident #105 had a medication cup with an unknown pill that was sitting on her bed side table. No staff were observed in the room or in the hall outside the room. Interview on 09/26/22 at 11:40 A.M. with Resident #105 revealed she had not taken her medication because she takes it after she eats. 366201 Page 48 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/26/22 at 11:51 A.M. with Unit Manager #318 revealed there was a medication cup with an unknown medication. Unit Manager #318 verified the medication in the cup was Lanthanum Carbonate (phosphate binder) 500 milligram (mg) chewable. 2. Review of the medical record for Resident #9 revealed an admission date of 02/07/22. Diagnoses included cellulitis of right lower limb, erythema intertrigo, non-pressure chronic ulcer of unspecified part of lower leg with severity, lymphedema, and obesity. Review of the MDS assessment, dated 08/18/22, revealed Resident #9 was cognitively intact. Review of Resident #9's physician order dated 09/07/22 revealed an order for Triamcinolone Acetonate (corticosteroid) cream 0.1% that should be applied daily to bilateral legs and feet. Observation on 09/28/22 at 3:10 P.M. of Resident #9 revealed Resident #9 had a cream in his dresser drawer in his room. The cream was Triamcinolone Acetonide cream at 0.1% and was stored in Resident #9's room. Interview on 09/28/22 at 3:11 P.M. with Resident #9 revealed the Triamcinolone Acetonide cream was used on his legs by another nurse and had come from the hospital. Interview on 09/28/22 at 3:15 P.M. with Unit Manager #318 confirmed the Triamcinolone Acetonide cream was in Resident #9's room and was not stored appropriately. Review of the Storage of Medications Policy, dated 04/2019, revealed the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 366201 Page 49 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on staff and resident interviews, review of the facility handbook, review of timesheets, and facility policy review, the facility failed to ensure a qualified social worker was on-site full-time when the facility had greater than 120 beds. This had the potential to affect all 128 residents who resided in the facility. The census was 128. Residents Affected - Many Findings include: Interview on 09/27/22 at 8:38 A.M. with Resident #32 revealed the facility did not have a full-time social worker on-site. Resident #32 stated a social worker was on-site two days a week. Interview on 09/28/22 at 11:15 A.M. with the Nursing Home Administrator (NHA) and Regional Nurse (RN) #420 revealed the facility's social worker recently walked out on the job without notice. The facility had two interim social workers who were on-site at the facility three to four days per week between the two of them. Interview on 09/29/22 at 1:18 P.M. with Social Services (SS) #501 revealed she and SS #500 were the interim social workers for the facility. SS #501 stated she was on-site two days a week. The previous full-time social worker had left the facility approximately one month ago. Interview on 10/03/22 at 9:10 A.M. with SS #500 revealed she was an interim social worker and was on-site one to two days per week. Review of the facility handbook revealed full-time status was reached when an employee worked at the facility for at least 30 hours per week. Interview on 10/03/22 at 4:30 P.M. with the NHA and RN #420 confirmed full-time status was reached when an employee worked at least 30 hours per week. The NHA and RN #420 stated SS #500 and SS #501 were on-site at the facility for at least 30 hours per week. Review of SS #501's hours worked from 08/31/22 through 09/29/22 revealed SS #501 worked 14.5 hours during the week from 08/28/22 to 09/01/22, 7.75 hours during the week from 09/05/22 to 09/09/22, 11 hours during the week from 09/12/22 to 09/16/22, and 7.75 hours during the week from 09/19/22 to 09/23/22. Review of SS #500's hours worked from 09/05/22 to 09/23/22 revealed SS #500 worked 16 hours during the week from 09/05/22 to 09/09/22, eight hours during the week from 09/12/22 to 09/16/22, and 16 hours during the week from 09/19/22 to 09/23/22. The total hours between SS #500 and SS #501 equaled: 23.75 hours during the week from 09/05/22 to 09/09/22, 19 hours during the week from 09/12/22 to 09/16/22, and 23.75 hours during the week from 09/19/22 to 09/23/22. The two interim social services employees did not meet the criteria of being a full-time employee. Interview via telephone on 10/04/22 at 3:15 P.M. with RN #420 confirmed SS #500 and SS #501 were not on-site at the facility for a total of 30 hours during the weeks of 09/05/22 to 09/09/22, 09/12/22 to 09/16/22, or 09/19/22 to 09/23/22. RN #420 stated she was not aware the interim social services employees were not meeting that criteria. 366201 Page 50 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0850 Review of the facility policy, Social Services, undated, revealed the policy stated, a facility with more than 120 beds will employ a qualified social worker on a full-time basis. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 366201 Page 51 of 52 366201 10/13/2022 Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure an indwelling Foley catheter was cleaned in accordance with proper infection control procedures. This affected one (#56) of one resident reviewed for catheter care. The facility identified there were four residents in the facility with catheters. The census was 128. Residents Affected - Few Findings include: Medical record review for Resident #56 revealed an admission date of 08/03/16. Medical diagnoses included multiple sclerosis, neurogenic bladder, and paraplegia. Review of the care plan, dated 03/11/20, revealed Resident #56 had an alteration in elimination related to a Foley catheter. Her diagnoses was neurogenic bladder. Her interventions were to provide Foley catheter care per orders and routine. Review of physician orders, dated 09/29/21, revealed Foley catheter care was to be provided every shift and as needed. Review of quarterly Minimum Data Set assessment, dated 07/12/22, revealed Resident #56 was cognitively intact. Observation of catheter care on 09/29/22 at 1:08 P.M. revealed Licensed Practical Nurse (LPN) #505 provided privacy, explained the procedure to Resident #56, prepared the water, and donned gloves. She proceeded to clean in downward motion on both sides of the labia using a different side of the cloth for each side, but only wiping the tubing going into the insertion site. Interview with LPN #505 on 09/29/22 at 1:18 P.M. confirmed she did not clean the tubing from the insertion site out and away from the catheter moving up the tubing. Review of policy titled Catheter Care, dated 11/01/17, revealed for a female to gently separate the labia to expose the urinary meatus. Wipe from front to back with a clean cloth moistened with water and perineal cleanser. Use a new part of the washcloth or a different cloth for each side. With a new moistened cloth, starting with the meatus moving out, wipe the catheter making sure to hold the catheter in place as to not pull on the catheter. Dry the area with a towel. 366201 Page 52 of 52