Health inspection·July 7, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to develop a comprehensive pressure ulcer plan of care. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 38. Findings include: Review of Resident #20's medical record revealed a 05/09/23 admission with diagnoses including depression, Alzheimer's disease, insomnia, dementia, hypothyroidism, Vitamin D deficiency, hyperlipidemia, anxiety, paralysis of vocal cords and larynx bilaterally, acute and chronic respiratory failure with hypoxia, gastroesophageal reflux disease, osteoarthritis of left shoulder, cervical disc disorder with myelopathy, low back pain, fibromyalgia, post laminectomy syndrome, long term use of opiate, tracheostomy status, right artificial hip, bilateral artificial knees, and bursitis of left shoulder. Physician orders on admission dated 05/09/23 included a pressure reduction mattress to bed, 05/09/23 cleanse right buttock with normal saline apply collagen particles and foam dressing Tuesday, Thursday and Saturday, encourage resident to turn and reposition. Review of a wound provider consult revealed a mistake a 05/24/23 Stage III pressure ulcer to the right pelvis, coccyx measuring 1.0 cm x 0.3 cm x 0.1 cm with moderate serous drainage was new when it was the same area the resident was admitted with. The facility did not develop a comprehensive pressure ulcer plan of care when the resident was admitted with an order for a dressing to the buttock. Interview on 06/26/23 at 6:02 P.M. with Director of Nursing (DON) #93 verified the resident was admitted with a pressure ulcer. The facility did not develop a comprehensive pressure ulcer assessment when the resident was admitted with a Stage III pressure ulcer. This deficiency represents non-compliance investigated under Complaint Number OH00143538. Page 1 of 35 366241 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review and interview, the facility failed to ensure a resident's fall plan of care was revised with new intervention. This affected one (Resident #36) of three residents reviewed for falls. The census was 38. Findings include: Review of Resident #36's medical record revealed a 04/28/23 admission with diagnoses including moderate protein calorie malnutrition, wedge compression fracture of thoracic vertebrae, dementia, Alzheimer's, Vitamin D deficiency, diverticuli of intestines, depression, anemia, hypertension, pneumonia, muscle weakness, dysphagia, irritable bowel syndrome, osteoarthritis, and abnormal findings in lung field. Review of the resident's 04/28/23 Morse Fall Risk scale revealed the resident was weak, and over estimates ability/limits and utilizes a wheelchair. Review of the 05/05/23 admission Minimum Data Set (MDS) revealed the resident was severely impaired for daily decision making, limited assist of two for bed mobility, extensive assist of two for transfers, one person physical assist for walking, extensive assist of two for dressing, toilet use and limited assist of one for personal hygiene. The resident had a fall with fracture prior to admission. Review of a risk for falls plan of care initiated 05/09/23 revealed the resident had risk of falls related to cognition, Alzheimer's disease, and bladder incontinence. Review of a post fall evaluation dated 05/25/23 at 10:54 A.M., included a fall was not witnessed. Fall occurred in the hallway. The resident stated she stood up to get the lady with the shovel. There was no apparent injury. The nurse heard resident yelling for help, when looking down the hallway, the resident was noticed to be sitting on the floor on her buttocks next to the 400 hall emergency exit door in front of her wheelchair with the wheels locked facing the exit door. #36 had her slippers on. The intervention was resident needs frequent monitoring and visual checks. The resident should be kept in common area so as to monitor activity. Review of the Fall plan of care revealed the plan of care was not updated with the intervention for frequent monitoring and visual checks, including resident should be kept in common area so as to monitor activity. Review of the resident's medical record revealed on 07/02/23 at 7:32 P.M. the resident had a fall from her recliner. The resident was not kept in the common area to monitor activity per the 05/25/23 post fall intervention. Interview on 07/03/23 at 7:34 P.M. with Director of Nursing (DON) #93 verified the fall plan of care was not updated post 05/23/23 fall to keep the resident in the common area. The DON included there was a binder at the nurse station with the updated fall interventions for the State Tested Nurse Aides. The DON verified the intervention to keep in the common area was not updated in the binder. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 2 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of Fire Department emergency response documentation, emergency room documentation, review of the facility policy titled Medical Emergencies, and interviews with residents, staff, and family, the facility failed to provide timely care and services for the monitoring and treatment of sign and symptoms of hypoglycemia (low blood sugar) for Resident #38, who had a diagnosis of diabetes mellitus. This resulted in Immediate Jeopardy with serious life-threatening harm on 06/08/23 at approximately 11:30 P.M. when State Tested Nursing Assistant (STNA) #131 and STNA #132 noted Resident #38 was cold and clammy when assisting him to bed but failed to immediately report this change in condition to the nurse until approximately two hours and 45 minutes later (around 2:15 A.M.). The resident was then discovered by Licensed Practical Nurse (LPN) #94 on 06/09/23 at 2:17 A.M. unresponsive with vomit on his bed and a blood sugar of 32 milligrams per deciliter (mg/dl) (per the Centers for Disease Control, a blood sugar below 70 mg/dl is considered hypoglycemic). Emergency Medical Services (EMS) was notified and Resident #38 was transferred to the emergency room where he was intubated, placed on a ventilator, treated for aspiration pneumonia and a myocardial infarction (MI), likely due to the hypoglycemia. The resident remained hospitalized for 12 days. This affected one resident (#38) of three residents reviewed for change in condition. The facility census was 38. Residents Affected - Few On 06/28/23 at 5:19 P.M., the Administrator and Director of Nursing (DON) #93 were notified Immediate Jeopardy began on 06/08/23 at approximately 11:30 P.M. when care and treatment was delayed for Resident #38 after direct care staff (STNA #131 and #132) failed to notify Licensed Practical Nurse (LPN) #94 when the resident presented with an acute change in condition; being cold and clammy indicative of hypoglycemia. The change in condition was not reported to the resident's nurse until 06/09/23 at approximately 2:15 A.M. at which time the resident was found to be unresponsive with a blood sugar of 32 mg/dl (hypoglycemic). The resident required emergency medical services and hospitalization for treatment as a result of the incident. The Immediate Jeopardy was removed on 06/29/23 when the facility implemented the following corrective actions: • On 06/15/23 at approximately 10:30 A.M. the Director of Nursing / Infection Preventionist (DON/IP), educated staff working in facility on the importance of notifying nurse immediately of any change in condition for residents. • On 06/16/23 at 12:00 P.M. the facility conducted a Quality Assurance Performance Improvement (QAPI) committee meeting with the Medical Director, DON/IP, Administrator, Minimum Data Set Registered Nurse (MDS/RN), and Social Service Designee (SSD). The meeting included: Identifying the problem of nurse aide failing to inform nurse of resident showing signs and symptoms of hypoglycemia resulting in resident sent to emergency room. 366241 Page 3 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Care conference to be scheduled upon Resident #38's return to facility. Level of Harm - Immediate jeopardy to resident health or safety Education provided to staff immediately on importance of notifying nurse on any change of condition Residents Affected - Few Pharmacy consulted per request of family for alternatives in monitoring blood sugars. identified by nurse aides. • On 06/27/23 at 8:00 P.M. the DON/IP, completed a Medication Error Report upon discovery of miscalculated dose of insulin administered on 06/08/23 at 9:30 P.M. for Resident #38. The nurse who committed the error was notified in person at facility of the error by DON/IP at 8:05 P.M. Education for this nurse and all other nurses related to medication administration/medication errors was completed on 06/28/23 and 06/29/23. • On 06/28/23 at 12:00 P.M. facility Administrator and DON had care conference with Resident #38's daughter, stepfather, ombudsman and ombudsman assistant to notify of the medication error and discuss plan of care moving forward. • On 06/28/23 at 6:00 P.M. the Medical Director provided standing orders and recommendations for updating the facility current Insulin Shock / Hypoglycemia policy and procedure. The facility indicated staff training would be completed on the updated policy on 06/28/23 and 06/29/23. • On 06/28/23 from 8:00 P.M. to 06/29/23 at 3:00 P.M. staff education was provided for all staff, including 11 licensed nurses, 21 STNAs, six laundry staff, five housekeeping staff, nine dietary staff, 10 administrative staff, five activity staff, two maintenance staff, four drivers/transportation and four therapy staff. Education included: New information in point click care under the care profile for each resident who was receiving insulin to monitor for signs and symptoms. Resident #38 had his care profile updated to labile diabetic and monitor for signs and symptoms. Additionally, monitoring for signs and symptoms was added to electronic treatment administration record (ETAR) for nurses to sign off every (q) shift. • 366241 Page 4 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety On 06/28/23, the DON and Administrator updated the facility Insulin Shock / Hypoglycemia policy and procedure based on the Medical Director's recommendations and standing orders. Additionally, a new policy for insulin administration per scale with formula was created. Furthermore, nursing staff were educated on the location of Glucagon vials for injection in emergency crash cart and that two would always be available. Residents Affected - Few • On 06/28/23, the facility implemented and educated all staff on the Early Warning Report form to be utilized when reporting signs and symptoms as an added back up to verbal notification and provide record of the initial verbal notification. These reports would be audited daily by DON/IP, CO-DON, and or RN Desk Nurse through review of form, progress notes and confirmation with nurse it was reported to. Additionally, floor nurses would review the importance of reporting signs and symptoms with nurse aides and other staff present during morning stand up meetings. The Risk Management Team would also audit nurse aides through interviews of six different nurse aides weekly for one month. Furthermore, the audit would also include review Early Warning Report forms weekly for one month to ensure staff were reporting signs and symptoms to nurses timely and accurately beginning in the week of July 1, 2023. The DON/IP completed one and one training of all licensed nursing staff personnel on the importance of adequate monitoring related to new protocol and procedures according to updated Insulin Shock / Hypoglycemia. • On 06/29/23 at 10:00 A.M. the DON/IP spoke with pharmacy to confirm and implement that the facility would now keep two vials of Glucagon in the crash cart for quicker response in a medical emergency. • On 06/29/23 at 1:25 P.M. the DON/IP completed an audit for Resident #10, who also received insulin utilizing formula. The audit reviewed May and June 2023 to ensure the resident was administered the correct dose of insulin if needed and/or to ensure the dose of insulin administered was calculated correctly. • On 06/29/23 the facility implemented a plan to monitor (beginning 07/01/23) for ongoing compliance of all outlined corrections weekly for two months and then monthly on a continuing basis thereafter. The monitoring would specifically audit that the Glucagon vials were in the emergency crash cart in the training center through direct visual inspection of the crash cart. Pharmacy would also complete their own audit of Glucagon vials being present in emergency crash cart during their normal monthly visits. Audits would be completed by the Risk Management Team which consists of MDS RN, Administrator, DON/IP and CO-DON. Additionally, the DON/IP, CO-DON & MDS RN would audit Resident #10 and #38 and any other resident who was admitted in the future for actual bloods sugar amounts and correct dose of insulin being administered through direct observation of nurse when taken and administered. The 366241 Page 5 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety monitoring would also be accomplished through chart review and direct observation of the electronic medication administration record (EMAR) and electronic treatment administration record (ETAR). The monitoring would also include auditing signs and symptoms section of the electronic treatment administration record (ETAR) that nurses were now signing every shift. This monitoring would occur three times a week with a different nurse each time for one month beginning 07/01/23 and then weekly for two months thereafter. Residents Affected - Few • All corrective actions outlined above would be reviewed in QAPI for effectiveness and compliance at next scheduled meeting in July 2023. • Interviews 06/30/23 between 1:22 P.M. and 1:53 P.M. with STNA's #97, #101, and #108 revealed they had been educated on the signs and symptoms of hyper and hypoglycemia. They were knowledgeable, able to verbalize symptoms and were aware they were to report signs and symptoms to the nurse. • Interviews 06/30/23 between 1:43 P.M. and 2:51 P.M. with Licensed Practical Nurses #88, #94 and Registered Nurse #92 verified the nurses were knowledgeable and able to verbalize signs and symptoms of hypo and hyperglycemia. The nurses were aware of the treatment for hyper and hypoglycemia. Further, they were knowledgeable regarding the new process to store two injectable glucagon in the crash cart and two in the emergency box. The new policy to count weekly the amount of available Glucagon injectables in the crash cart weekly. In addition, the nurses were educated to check the dosage of insulin coverage for accuracy. Although the Immediate Jeopardy was removed on 06/29/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility from home on [DATE]. Resident #38 had diagnoses including chronic obstructive pulmonary disease, thoracic thoracolumbar and lumbosacral intervertebral disc disorder, hypercholesterolemia, osteoarthritis, and hyperlipidemia. The resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE] with additional diagnoses that included encephalopathy, acute respiratory failure, Type 1 diabetes mellitus (body does not make insulin), pneumonia, seizures, abnormal plasma proteins, altered mental state, convulsions, and hyperglycemia. Record review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #38 was independent for daily decision with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment revealed the resident was able to understand others and be understood, he had no behaviors. Resident #38 required limited assistive of two staff for bed ability, extensive assistant of two staff to transfer, assist of two staff to walk in room, limited assistance of one staff to walk in corridor, extensive assistive of two staff for dressing, extensive assistive of one 366241 Page 6 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few staff for eating, limited assist of one staff for toilet and personal hygiene. The resident had a loss of liquids and solids from mouth when eating or drinking and coughing or choking during meals and when taking medications. The resident utilized the wheelchair. Resident #38 was occasionally incontinent of urine and always incontinent of stool. The assessment noted the resident received insulin injections seven day a week. Resident #38's admission physician orders included blood sugar monitoring four times a day without (insulin) coverage for the diagnosis of diabetes mellitus. Medication orders included NovoLog Mix 70/30 subcutaneous suspension (70-30) (a long-acting insulin) 100 Units/milliliter, inject 20 unit subcutaneously in the morning for diabetes and inject 12 unit subcutaneously in the evening for diabetes. This medication was ordered to be given routinely each day. Record review revealed on 06/02/23 Resident #38 required one on one (1:1) staff supervision for all meals for safety due to aspiration risk. Record review revealed from admission [DATE] through 06/05/23) Resident #38's blood sugar levels ranged from 78 mg/dl to 482/dl, generally in the 200 mg/dl to 350 mg/dl range. On 06/05/23 Medical Director (MD) #134 became the physician of record for Resident #38. A new order was received on this date for Novolog (insulin) coverage (a rapid acting insulin) via a sliding scale four times a day for blood sugars using a formula for blood glucose levels greater than 150. For blood glucose levels above 150, staff would divide the result by 30 and minus 3 to determine the number of Novolog units to administer subcutaneously. The sliding scale coverage was to be used following blood glucose monitoring daily at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 10:00 P.M. Review of the medical record revealed Medical Director (MD) #134 visited and met the resident for the first time on 06/08/23 at approximately 3:40 P.M. Medical Director #134 wrote orders to fax blood sugar results every shift until 06/12/23, to increase the morning dose of routine NovoLog Mix 70/30 subcutaneous suspension (70-30) 100 units/ML (Insulin Aspart Protamine & Aspart (Human)) to 30 units subcutaneously in the morning for diabetes (an increase of 10 units), inject 10 units subcutaneously in the afternoon for diabetes (added the new afternoon dose) and inject 12 units subcutaneously in the evening for diabetes (no change in dosage). Review of the 06/08/23 physician progress note included chronic obstructive pulmonary disease had been stable despite the presence of rhonchi on exam at this time. Diabetes mellitus has been sub-optimally controlled, and medications would be adjusted. The resident had significant expressive dysphasia however, conversation could be completed satisfactorily. Review of the meal intake record revealed Resident #38 did not eat breakfast on 06/08/23 and ate 76-100 percent for both lunch and supper. Review of the medication administration record (MAR) revealed on 06/08/23 the resident's 4:00 P.M. blood sugar was 204 and the resident was administered four units of insulin. The 10:00 P.M. blood sugar was 290 and the resident was administered 10 units Novolog insulin, which was an error as the resident should have been administered seven units. Review of Resident #38's nurse's notes revealed on 06/09/23 a 5:44 A.M. late entry note entered by Licensed Practical Nurse (LPN) #94 revealed at 2:17 A.M. STNA #131 reported to this nurse the resident was cold and clammy. Upon entering resident's room, the resident was breathing heavily with vomit 366241 Page 7 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on right side of bed. When this nurse called out resident's name, the resident did not respond. The LPN walked closer to resident's bedside called out again with no response. Began sternal rubs with no response. This nurse ran to cart and grabbed blood pressure cuff, pulse oximeter and glucometer. Blood pressure was 122/77 millimeters of mercury (mm/Hg), temperature was 98.0 degrees Fahrenheit, respirations 22 per minute, pulse 94 beats per minute, oxygen saturation 97 percent on room air. Blood glucose monitoring was 32 mg/dl . Glucagon gel administered and blood glucose increased to 37 mg/dl. 911 called at 2:20 A.M. to transport resident to emergency room for evaluation and treatment. This nurse stayed with resident at bedside until emergency medical technicians (EMT) arrived at 2:33 A.M. EMT immediately started an intravenous line and dextrose was administered. The resident's blood glucose increased to 302 mg/dl. The LPN assisted EMT staff to get resident onto the gurney. Resident left the building with the Fire Department at 2:47 A.M. Review of the Fire Department (EMT) record for this incident revealed they received the call at 2:21 A.M., arrived at 2:29 A.M. and found the resident unresponsive. EMTs placed an intravenous line and administered 25 grams of glucose intravenously. At 2:40 A.M. the resident's blood sugar was 302. A non-rebreather mask was placed at 12 liters of oxygen per minute. Response improved but the resident was still unresponsive. Skin was clammy and diaphoretic. The resident was pale. Pupils three millimeters (mm) and sluggish. Departed facility at 2:41 A.M., arrived at the emergency room 2:46 A.M. and transferred to emergency room cart 2:48 A.M. Review of the Emergency Department documentation revealed on 06/09/23 at 2:50 A.M. Resident #38 was brought in with a 95% oxygen saturation, and respirations of 17 breaths per minute. The resident was intubated and placed on a ventilator by 3:00 A.M. An electrocardiogram revealed the resident likely has non-ST elevated myocardial infarction (NSTEMI) secondary to hypoglycemia. A CT scan of lungs revealed apparent bilateral infiltrates (secondary to possible aspiration pneumonia). The resident was monitored in the emergency room by a critical care nurse until 6:00 P.M. 06/09/23 when a bed opened, and he was then transferred to a larger medical center. The resident remained stable although critical requiring intubation and central line placement. Diagnoses included altered mental status and possible aspiration pneumonia. Resident #38 was discharged back to the facility on [DATE] with diagnoses including change in mental status, elevated troponin levels, hyperglycemia, pneumonia, acute respiratory failure, and seizure. Additional diagnoses included provoked seizure, uncontrolled type 1 diabetes mellitus with hypoglycemia. Interview on 06/27/23 at 2:42 P.M. with DON #93 revealed it was discovered STNA #131 and #132 reported Resident #38 was cool and clammy around 11:30 P.M. when they put him to bed the night of 06/08/23. STNA #131 reportedly asked STNA #132 if the resident was diabetic and she said no. Hours later in conversation, STNA #131 told the nurse the resident was cold and clammy when they put him to bed which prompted the nurse to go check him. Upon checking on the resident, he was found unresponsive. STNA #132 was suspended 06/09/23 and terminated 06/12/23 for failure to report in part because she did not seem to understand the seriousness of not reporting a change in condition when the resident was cold and clammy. Interview on 06/27/23 at 5:52 P.M. with RN #96 revealed she was on duty 06/08/23 from 6:00 P.M. until 10:00 P.M. Resident #38 was in the lounge watching television and she asked him if he had a snack and he said yes. RN #96 revealed Resident #38 was usually the last resident to bed. The RN stated she obtained the resident's blood sugar at 9:30 P.M. and it was 290 mg/dl and she administered the 366241 Page 8 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sliding scale insulin coverage of 10 units of Novolog insulin. At the time of the interview, RN #96 was unaware she had not administered the correct dose of insulin and had given the resident three units of insulin too much. The RN concluded with the formula blood sugar divided by 30 minus three she must not have subtracted the three units. Interview on 06/27/23 at 6:15 P.M. with LPN #94 revealed she had a conversation with Resident #38 on the evening of 06/08/23. The resident was eating a snack about 11:00 P.M. in the front television area. She knew he had a drink but was unsure what the snack was. LPN #94 reported STNA's #131 and #132 said that they took the resident back to his room around 11:30 P.M. STNA #131 told LPN #94 in conversation after 2:00 A.M. that Resident #38 was cold and clammy when they put him to bed. STNA #131 said she asked STNA #132 if the resident was diabetic, and the STNA said no. LPN #94 stated she had checked on the resident through the night from the doorway and he appeared to be sleeping, so she did not turn on the light in the room. She could not tell if the resident was cold and clammy during her observations. After STNA #131 reported to her the resident had been cold and clammy when assisted to bed, she immediately went back to check him (around 2:15 A.M.), and she heard gurgling respirations from the door. When she turned on the light in the room, she noted the resident had vomited on his bed. She yelled his name twice and received no response. She had no response from a sternal rub. LPN #94 put on the call light, and no one came. She ran out and got equipment. STNA #131 saw her and came back to the room. STNA #131 had her phone and the LPN stated she told the STNA to call 911 and then proceeded to try to check the resident's blood (glucose) sugar. LPN #94 had a hard time getting blood for the blood sugar. The resident's blood sugar was low at 32 mg/dl. The LPN stated she ran out of the resident's room and found glucagon gel. She stated it was all she could find. She could not find injectable glucagon. She squirted the gel in the resident's cheek and massaged it. She knew she was not to give it orally when a resident was unconscious, but she didn't know what else to do to help him. The gel got Resident #38's blood sugar up to 37 mg/dl. The squad came and started an intravenous (IV) and pushed glucose IV. His blood sugar was 300 plus after they administered the IV glucose. When EMT staff got the resident on the gurney, he started having seizure like activity and was still not responding. The resident was transferred to the hospital. The LPN contacted the resident's daughter later and was told the resident was intubated, and they were waiting to transfer him to another hospital when a bed opened. LPN #94 said if the STNA staff had told her the resident was cold and clammy at the time they put him to bed, she would have assessed him and intervened at that time. LPN #94 revealed the whole situation could have been avoided if she was told he was having symptoms when the staff assisted him to bed at 11:30 P.M. Interview on 06/28/23 at 2:38 P.M. with DON #93 verified STNA #131 and #132 did not report timely a change in Resident #38's condition. Further interview verified the facility failed to investigate to determine if there were any other reasons why the resident's blood glucose level would have dropped so low. The facility had not investigated whether the resident was administered the correct amounts of insulin prior to the incident. The facility did not complete an investigation to determine if the appropriate interventions were available and provided during the emergency, including the availability of injectable glucagon. On 06/28/23 at 2:23 P.M. Resident #38 was observed sitting in his wheelchair. The resident was alert and his speech was slow but comprehensible. The resident indicated the night he went into the hospital, he did not remember if he felt ill. He said he remembered feeling tired. Telephone interview on 06/28/23 at 4:55 P.M. with MD #134 revealed he just took over the care of Resident #38 and was adjusting his insulin to better control the resident's blood sugars. The MD did not think giving three extra units of Novolog insulin would drop a blood sugar to 32 mg/dl. He 366241 Page 9 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety questioned whether there was an infection or some other process in play. He indicated the nursing home doesn't have intravenous glucose on hand, they leave it up to the emergency team. However, they should have the glucagon for injection for emergencies. He indicated he would work with the facility to ensure the nurses have the medication needed on hand and staff have the proper education to alert the nurses of change. There was a Glucagon 1 mg in the emergency kit. It was dated 05/24/23. So, it should have been there when the nurse looked that night. Residents Affected - Few Interview on 06/28/23 at 5:55 P.M. with LPN #89 revealed the medication room was to have two injectable Glucagon, but stated there was a problem keeping them stocked. She indicated on 05/24/23 she had a resident whose blood glucose dropped to 49 mg/dl on one hand and 43 mg/dl on the other hand. The Medical Director ordered 1 mg of Glucagon and when that nurse went in the medication room, and they had no injectable medication. She said the resident was alert, so she was able to give the gel and this resident's blood sugar went up to 82. She said she called the pharmacy and told them they needed two sent. Observation of the medication room on 06/28/23 at 5:55 P.M. revealed the emergency box had one injectable Glucagon labeled 05/24/23. Interview on 06/29/23 at 11:18 A.M. with STNA #132 revealed she was one of the two aides to put Resident #38 to bed the night of 06/08/23. STNA #132 stated she did not touch Resident #38's skin and feel if it was cold or clammy. The other aide said he was cold and clammy. She doesn't remember being asked if he was diabetic. STNA #132 did not know if the resident was diabetic or not. STNA #132 also said she did not know being cold and clammy was a sign of a blood sugar dropping. She indicated she was outside when the other staff went to his room about 2:30 A.M. When she arrived, the nurse was taking his blood pressure. He had something red coming out of his mouth. He had rattly respirations. The nurse was yelling they did not have the proper things to take care of him. They gave him a gel in his mouth. The STNA stated she told the nurse she did not know if someone was cold and clammy that was a sign of a diabetic reaction. The STNA stated, if the resident was a high-risk diabetic, she should have been told of the situation. She again stated she didn't know the resident was a diabetic. Review of the email from the Administrator on 06/29/23 at 1:06 P.M. revealed DON #93 confirmed the error in the amount of insulin coverage the resident had received received as noted above. Interview on 06/29/23 at 4:16 P.M. with STNA #131 revealed Resident #38 was the last person they put to bed that night (06/08/23) because she was told he liked to stay up. The STNA revealed the resident's skin was very cold to the touch when they (she and STNA #132) put him to bed. He was shaking a lot but was talking. The STNA stated she asked the other aide if the resident was diabetic, and she said no. The resident did not appear to be sweating. She stated if he wasn't she wouldn't have even asked the other aide if he was diabetic and would have reported the situation to the nurse. After everything settled down (the residents were all in bed, etc), she stated staff were talking about situations and things learned over the years. She said she brought up about a resident who was cold and sweating a lot and he was having a diabetic reaction and that made her think of Resident #38 and how cold he was when he was assisted to bed. The STNA said she asked the other aide if he was diabetic, and she said no. The STNA revealed the nurse then looked at her and said, yes, he was a diabetic and ran back there (to his room) and found him not responding. When the STNA got there, he had thrown up on his left shoulder. The STNA stated she was only an aide; she had seen diabetic reactions from her experience but in nurse aide training they really do not go into the signs and symptoms of diabetes. 366241 Page 10 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Review of the facility policy, titled Medical Emergencies, dated 03/18/15 revealed for insulin shock nursing staff would be familiar with the symptoms and treatment of insulin shock. Symptoms of insulin shock were sweating, restlessness, vertigo, pallor or flushing face, weakness, diplopia, dilated pupils and increase pulse. Call for help and stay with the resident. If the victim was conscious and able to swallow you may give orange juice. Use glucose or comparable product per directions. Notify physician and provide treatment as directed. Residents Affected - Few This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 11 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, policy review, and staff interview, the facility failed to ensure a vision exam was completed as recommended. This affected one (Resident #3) of three residents reviewed. The facility census was 38. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed an admission date of 05/23/19 with diagnoses that included Alzheimer's disease with dementia, end stage heart failure and cerebrovascular accident with hemiplegia. Review of the 05/25/23 Annual Minimum Data Set Assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two for bed mobility, transfers, walking, dressing, toileting, personal hygiene and assist of one for meals. The resident had upper and lower extremity functional impairment of both sides. The resident had incontinence of bowel and bladder. The resident was on hospice services and on pressure reducing bed and chair. The resident had adequate vision. Record review revealed the resident's last had a vision exam on 06/17/21. The physician recommended an exam in 12 months. There was no evidence of an annual exam since 06/17/21. Review of the facility's Ancillary Services policy dated 03/2022 included the facility will provide ancillary services to all residents when needed on a routine and emergency basis. Interview on 06/30/23 at 2:27 P.M. with Social Services Designee #117 verified Resident #3 did not have her annual vision exam as recommended. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 12 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate treatment and assessment of pressure ulcers. This affected three (Resident's #3, #20 and #41) of three sampled residents. The facility census was 38. Residents Affected - Few Findings include: 1. Review of Resident #3's medical record revealed an admission date of [DATE] with diagnoses that included Alzheimer's disease with dementia, end stage heart failure and cerebrovascular accident with hemiplegia. The resident had a plan of care dated [DATE] of potential for pressure injury development related to decreased mobility, fragile skin and incontinence, anemia, cardiac insufficiency and cognitive impairment. Interventions included a [DATE] order to apply skin barrier as needed and a [DATE] order to administer treatments as ordered. Physician orders included on [DATE] a pressure reduction mattress to bed, [DATE] apply skin barrier ointment to skin area as preventative, may apply daily and as needed every day and night shift, [DATE] weekly skin assessment on Mondays, and [DATE] dressing to coccyx clean with normal saline solution, apply medi-honey and foam dressing daily. Complete a weekly skin assessment every Monday. Review of the [DATE] Annual Minimum Data Set Assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two for bed mobility, transfers, walking, dressing, toileting, personal hygiene and assist of one for meals. The resident had upper and lower extremity functional impairment of both sides. The resident had incontinence of bowel and bladder. The resident was on hospice services and on pressure reducing bed and chair. Review of skin assessments revealed a gluteal crease wound was discovered [DATE]. On [DATE], the ulcer measured 1.7 centimeters (cm) x 0.5 cm x 0 unstageable (defined as full thickness skin or tissue loss with unknown depth. Full thickness tissue loss is when the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). The [DATE] assessment revealed 1.4 cm x 0.6 cm x 0.1 cm and remained unstageable. There was no evidence of a [DATE] pressure ulcer assessment. Review of the record revealed an order for skin barrier ointment to skin area as preventative, may apply daily and as needed every day and night shift. Review of the resident's medical record revealed this was not signed off as completed by night shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the May and [DATE] treatment sheets revealed the daily dressing to coccyx/buttocks gluteal crease, (clean with normal saline solution, apply medi-honey and foam dressing), was not signed off as changed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no evidence of a weekly skin assessment completed on [DATE] and [DATE]. 366241 Page 13 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse notes included on [DATE] the nurse was made aware of an open area to the coccyx. The assessment indicated it was a Stage III (defined as full thickness skin loss potentially extending into the subcutaneous layer) 90 percent slough and 10 percent granulation 2 cm x 1.0 cm x 0.1 cm, a medi-honey and foam dressing was ordered. Interview on [DATE] at 5:02 P.M. with the Director of Nursing (DON) #93 verified a [DATE] weekly skin assessment was not completed and six day later the staff discovered a Stage III pressure ulcer to the coccyx. The DON #93 revealed the weekly [DATE] pressure ulcer assessment was not completed because the wound nurse was on vacation. DON #93 stated DON #95 would be responsible for completing the assessment when the wound nurse was off. Further, the DON #93 verified there were many daily dressing changes that were not signed as completed as well as the application of barrier cream. Review of the facility's Pressure Ulcer policy (dated 03/2022) included assess skin on admission, weekly, and as needed. When a pressure ulcer develops wound tracking is to be done weekly. Review of the facility's Pressure Ulcer Wound Tracking policy (dated 03/2022) included the treatment nurse will chart weekly on residents with skin problems. Included on the chart will be measurements tissue types, drainage, progess etc. Review of the facility's Dressing Change policy (dated 03/2022) included all wounds are treated and dressed according to a physicians order. Review of the facility's Body's Checks policy (dated 08/2018) included all residents will be checked for decubuti or skin problems weekly by nurse. A head to toe body check will be done weekly or as needed. 2. Review of Resident #20's medical record revealed a [DATE] admission with diagnoses including depression, Alzheimer's disease, insomnia, dementia, hypothyroidism, Vitamin D deficiency, hyperlipidemia, anxiety, paralysis of vocal cords and larynx bilaterally, acute and chronic respiratory failure with hypoxia, gastroesophageal reflux disease, osteoarthritis of left shoulder, cervical disc disorder with myelopathy, low back pain, fibromyalgia, post laminectomy syndrome, long term use of opiate, tracheostomy status, right artificial hip, bilateral artificial knees, and bursitis of left shoulder. Review of the resident's admission Braden Scale assessment dated [DATE] revealed the resident was a low risk for pressure ulcers. Review of Physician orders included [DATE] pressure reduction mattress to bed, [DATE] cleanse right buttock with normal saline apply collagen particles and foam dressing Tuesday, Thursday and Saturday, encourage resident to turn and reposition, and [DATE] wound clinic consult for scar edge excision. The admission skin assessment revealed no documentation of a pressure ulcer. There were no measurements or description of a skin impairment for the ordered dressing to the right buttock. The baseline care plan did not address pressure ulcer care or skin impairment. Review of the [DATE] admission MDS revealed the resident was independent for daily decision making, independent for bed mobility, transfer, walking, dressing, eating, toilet, and a one person assist 366241 Page 14 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for personal hygiene. The resident had no upper or lower extremity impairment. The resident had no pressure ulcers. Review of a wound provider consult revealed a mistake as a [DATE] Stage III pressure ulcer to the right pelvis, coccyx measuring 1.0 cm x 0.3 cm x 0.1 cm with moderate serous drainage was new when it was the same area the resident was admitted with. A [DATE] order to cleanse coccyx with normal saline, apply alginate and foam dressing daily and as needed was written. There was not a weekly skin assessment on [DATE]. The facility did not develop a comprehensive pressure ulcer plan of care when the resident admitted with an order for a dressing to the buttock. Interview on [DATE] at 4:52 P.M. with Wound Consultant #136 revealed the resident did not have a new pressure ulcer on [DATE]. The description for the right pelvis coccyx was the same area (Right buttock) the resident was admitted with on [DATE]. Wound Consultant #136 revealed she also consulted with the resident's previous facility prior to the [DATE] admission. The pressure ulcer was discovered [DATE] and was a Stage III pressure ulcer prior to the [DATE] admission. Review of the resident's treatment sheets revealed starting [DATE] the nurses were signing off an order to cleanse coccyx with normal saline, apply alginate and foam dressing daily, and right buttock with normal saline, apply collagen particles and foam dressing Tuesday, Thursday and Saturday when the resident only had one open area not two. The daily alginate dressing was signed off as changed daily except for [DATE], [DATE], [DATE], [DATE] and [DATE]. The three times a week collagen dressing was signed off as completed except for [DATE], [DATE], and [DATE]. Interview on [DATE] at 6:02 P.M. with DON #93 verified there was no pressure ulcer assessment of the Stage III pressure ulcer on admission. DON #93 verified from [DATE] until [DATE] there was no assessment of the ulcer. The DON verified on [DATE] the collagen dressing to the right buttock should have been discontinued. The DON verified the nurses were signing off both dressings as being applied when there was only one wound. The DON further verified the [DATE] pressure ulcer assessment was not completed because the wound nurse was on vacation. DON #93 stated DON #95 would be responsible for completing the wound assessment when the wound nurse was off. The DON further verified there were days when dressing changes were not signed off as completed. 3. Review of Resident #41's closed medical record revealed a [DATE] admission with diagnoses including Alzheimer's disease, idiopathic peripheral autonomic neuropathy, depression, restlessness and agitation, anxiety disorder, dementia with behavioral disturbance, dysphagia, psychosis, hyperlipidemia, hypertension, psychotic disorder with delusions, and Parkinson's disease. The resident expired [DATE]. Review of the resident's [DATE] Quarterly Minimum Data Set Assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two for bed mobility, transfers, did not walk, required extensive assist of two for dressing, toileting, personal hygiene and extensive assist of one for meals. The resident had no upper or lower extremity functional impairment. The resident had incontinence of bowel and bladder. The resident was on hospice services and on pressure reducing bed and chair. Review of the resident's pressure ulcer assessments included a left lateral lower extremity unstageable pressure ulcer developed [DATE]. On [DATE] the ulcer measured 3.8 cm x 3.2 cm x 0.1 with 366241 Page 15 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0686 Level of Harm - Minimal harm or potential for actual harm moderate serous drainage. Dakins 0.125 percent moist gauze and a dry dressing was ordered daily on [DATE]. On [DATE] an order was written to cleanse left lateral ankle with normal saline, alginate and foam dressing daily and as needed. The dressing was not signed as applied [DATE]. The Dakins dressing was not discontinued and the nurses were signing on the treatment sheets they were applying both dressings to the same area from [DATE] until [DATE]. Residents Affected - Few Review the resident's record revealed a right lower extremity suspected deep tissue injury developed [DATE]. The ulcer measured 1.0 cm x 1.0 cm x 0.05 cm on [DATE] and was left open to air. On [DATE] an order for foam to the right lateral ankle wound three times a week every Tuesday, Thursday and Saturday was ordered. The leave open to air should have been discontinued but it was not. The nurses were signing off they were changing the dressing and leaving the area opened to air. The foam dressing was not signed off as applied on [DATE]. The treatment sheet had leave area opened to air signed off from [DATE] through [DATE] at the same time the foam dressing was signed as applied. There was not a weekly pressure ulcer assessment completed on [DATE]. Review of the resident's record revealed a [DATE] order to float ankles and heels off bed every day and night. The record revealed floating heels was not signed off on nights [DATE], [DATE], [DATE], and [DATE]. There was not a weekly pressure ulcer assessment completed on [DATE]. Interview on [DATE] at 2:59 P.M. with DON #93 verified she was unable to determine which dressing was being applied to the left lower ankle. The DON verified the staff was signing off contradictory orders for the resident's pressure ulcers. DON #93 further verified there was not skin assessments completed weekly on [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00143538. 366241 Page 16 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on record review and staff interview, the facility failed to ensure restorative services were provided as ordered. This affected two (Residents #11 and #34) of three residents reviewed for restorative services. The facility identified 23 residents on restorative programs. Findings include: 1. Review of Resident #11's medical record revealed a 03/16/22 admission with diagnoses including anemia, dysphagia, myocardial infarct, Stage III chronic kidney disease, osteoarthritis, Vitamin D deficiency, and atherosclerotic heart disease. Review of the quarterly 06/14/23 Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision making, required extensive assist of two for bed mobility, transfer, toilet, did not walk, limited assist of one for dressing, and extensive assist of one for personal hygiene. The resident had no upper or lower functional limitations. The resident utilizes a wheelchair and had passive range of motion two days in the look back period. Review of the 04/03/23 Active Range of Motion (AROM) Program #1 revealed AROM to bilateral upper extremities (BUE) six to seven days a week two times a day. Resident is stiff and needs encouragement to relax at times. Watch for pain and/or discomfort. Directions: 1. Bilateral Shoulders: Cue to perform 10 repetitions to bilateral shoulders while in lying position in bed. Forward flexion and extension, abduction and adduction, external/internal rotation. 2. Bilateral Elbows/wrists: Cue to perform 10 repetitions of flexion and extension. 3. Bilateral forearms: Cue to perform range of motion (ROM) to forearms, x 10 repetitions of supination and pronation. 4. Fingers/thumbs of bilateral hands: Cue to perform, 10 repetitions of flexion, extension, abduction, and adduction. Goal: will not develop contracture's associated with stiffness to BUE/prevent decline in movement. Review of the medical record revealed an Active ROM Program #2 Restorative - Active ROM Program #2 AROM to bilateral lower extremities (BLE) six to seven days a week two times a day. Resident is stiff and needs encouragement to relax at times. Watch for pain and/or discomfort. Directions: While lying in bed, resident will perform: 1. Bilateral hips: Cue to perform, 10 repetitions of abduction, adduction, external rotation, and internal rotation. 2. Bilateral ankles: Cue to perform, 10 repetitions of dorsal flexion, plantar flexion, eversion, and inversion. 3. Bilateral hips/knees: Cue to perform, 10 repetitions of flexion and extension. Goal: will not develop contracture's associated with stiffness to BLE/prevent decline in movement. Review of the restorative documentation from 06/01/23 to 06/30/23 revealed the upper and lower extremity programs were performed 10 times in 30 days. The program goal was twice a day six to seven days a week to provide 52 to 60 programs a month. Interview on 06/30/23 at 3:34 P.M. with Registered Nurse (RN) #87 verified the AROM programs were not completed at the frequency scheduled. RN #87 revealed they have a restorative aide that gets pulled to work the floor and the AROM programs are not being completed. 2. Review of Resident #34's medical record revealed a 03/27/08 admission with diagnoses including muscle wasting and atrophy of right and left lower extremities, multiple sclerosis, paraplegia, hypertension, protein calorie malnutrition, Vitamin D deficiency, hyperlipidemia, and diaphragmatic 366241 Page 17 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0688 hernia. Level of Harm - Minimal harm or potential for actual harm Review of the 04/14/23 quarterly MDS included the resident required total dependence of two for bed mobility, transfer, dressing, toileting, did not walk, and totally dependent of one for eating. Residents Affected - Few Review of the recrod revealed a restorative Passive Range of Motion (PROM) Program #1 that included PROM to bilateral hands and wrists with one staff assist with PROM seven days/week. Directions: Perform PROM as directed below prior to applying splint and after removing splint (rolled wash cloth to bilateral hands). 1. PROM to bilateral hands (fingers/thumbs): Staff to perform five to seven repetitions of flexion, extension, abduction and adduction. Splint/Brace Assistance Program #1 Direction: Splinting/rolled wash cloth to be applied seven days a week- on in morning and off in evening. 1. Prior to application of rolled wash cloth to bilateral hands related to contracture's and after removal- perform PROM as indicated in PROM restorative nurse program (RNP). 2. Apply splint/rolled wash cloth in morning and remove in evening. 3. After removal of rolled wash cloth to bilateral hands related to contracture's- perform PROM as indicated in PROM RNP, assess skin, and cleanse hands as needed. Goal: prevent further decline in bilateral hand ROM associated with contracture's. Review of the restorative documentation revealed the program was completed 14 of 30 days. The goal was seven days a week, 30 of 30 days. Interview on 06/30/23 at 3:34 P.M. with Registered Nurse (RN) #87 verified the programs were not completed at the frequency scheduled. RN #87 revealed they have a restorative aide that gets pulled to work the floor and the programs are not being completed. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 18 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to ensure fall safety and monitoring measures were in place as ordered. This affected two (Resident's #25 and #36) of three residents reviewed for falls. Findings include: 1. Review of Resident #25's medical record revealed the resident was admitted [DATE] with diagnoses including depression, unspecified neck injury, pneumonia, hypothyroidism, hyperlipidemia, polyneuropathy, muscle wasting and atrophy, chronic obstructive pulmonary disease, congestive heart failure, paroxysmal atrial fibrillation, hypertension, fibromyalgia, irritable bowel syndrome, anxiety disorder, gastroesophageal reflux disease, chronic gastric ulcer, anemia, nicotine dependence and hemorrhoids. Review of the Fall plan of care dated 01/10/23 included the resident was at risk for falls related to fall with cervical fracture prior to admission, need for assistance with activities of daily living, pain associated with fracture/fibromyalgia/Gastrointestinal reflux disease, /Irritable bowel syndrome, cognitive impairment, inattention/disorganized thinking, and respiratory insufficiency requiring supplemental oxygenation. Interventions included on 01/11/23 recliner function to not be utilized on chair in room. Added dycem to chair in room. Review of the Quarterly 05/03/23 Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, required extensive assist of two for bed mobility,transfers,walk with assist of two, toileting, limited assist of one for dressing, extensive assist of one for personal hygiene. There were no falls since last assessment. Physician orders included a 01/11/23 order for dycem to chair in room. Review of an Incident Note dated 06/11/23 at 2:30 PM revealed observed resident in a sitting position outside of her room, back to room and feet to wall, socks off. Observed hematoma on right forehead, dark purple with bright red color in areas. Resident stated I slid out of the bed and hit my head on wheelchair, have little pain on forehead. No pain in neck at this time. A neurological check was performed. Review of the incident revealed there were not neurological checks continued related to the resident hitting her head. The only other set of neurological checks was completed 06/13/23 at 3:03 P.M. The resident was noted to have large dark purple bruise to right eye and forehead. The resident voiced complaints earlier this shift of pain and discomfort, no complaints at this time. There was no evidence of a 72 hour post fall monitoring note. Review of a Nurse Note dated 06/24/23 at 4:06 P.M. revealed while going past resident room, observed her sitting on mat at bedside on floor. Further review of the nurse notes revealed there was no evidence of a 72 hour post fall monitoring note per policy. 366241 Page 19 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0689 Observation on 06/30/23 at 1:43 P.M. revealed the resident was sitting in her recliner. Level of Harm - Minimal harm or potential for actual harm Interview on 06/30/23 at 2:45 P.M. with Licensed Practical Nurse (LPN) #88 verified there was no dycem in the recliner as ordered. Residents Affected - Few Interview on 07/03/23 at 7:34 P.M. with Director of Nursing (DON) #93 verified the resident had a fall with a hematoma on her head and the facility did not have neurological checks completed to monitor her condition. DON #93 further verified the resident did not have a 72 hour post fall note. Review of the facility's Resident Incidents policy (dated 09/2022) included if a resident falls, complete a post fall 72 hour monitoring report. The assessment should be completed during the intervals specified on the sheet for follow up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. 2. Review of Resident #36's medical record revealed a 04/28/23 admission with diagnoses including moderate protein calorie malnutrition, wedge compression fracture of thoracic vertebrae, dementia, Alzheimer's, Vitamin D deficiency, diverticuli of intestines, depression, anemia, hypertension, pneumonia, muscle weakness, dysphagia, irritable bowel syndrome, osteoarthritis, and abnormal findings in lung field. Physician orders included an order dated 04/28/23 for dycem in wheelchair. The resident was a high fall risk on the Morse Fall Risk scale (dated 04/28/23), resident was weak and over estimates ability/limits and utilized a wheelchair. Review of the 05/05/23 admission MDS revealed the resident was severely impaired for daily decision making, required limited assist of two for bed mobility, extensive assist of two for transfers, one person physical assist for walking, extensive assist of two for dressing, toilet use and limited assist of one for personal hygiene. The resident had a fall with fracture prior to admission. Review of a risk for falls plan of care initiated 05/09/23 revealed the resident was at risk for falls related to cognition, Alzheimer's, and bladder incontinence. Interventions included a 05/09/23 order for dycem to wheelchair. Review of a post fall evaluation dated 05/25/23 at 10:54 A.M. revealed fall was not witnessed. Fall occurred in the hallway. Resident stated, Stood up to get the lady with the shovel. There was no apparent injury. The nurse heard resident yelling for help, when looking down the hallway resident was noticed to be sitting on the floor on her buttocks next to the 400 hall emergency exit door in front of her wheelchair with the wheels locked facing the exit door. Resident had her slippers on. The intervention was resident needs frequent monitoring and visual checks. Resident should be seated in common area so as to monitor activity. There was not a 72 hour post fall note per policy. Observation on 06/30/23 at 2:43 P.M. revealed the resident was in the dining room in her wheelchair. State Tested Nurse Aides (STNA) #101 and #115 stood the resident up and were unable to locate dycem in her wheelchair above or below the cushion as ordered. STNAs #101 and #115 verified the resident did not have dycem in her wheelchair as ordered. Review of a Nurse Note dated 07/02/23 at 7:32 P.M. revealed Housekeeping/Laundry notified STNA that resident was noted to be sitting on the floor in front of her recliner at 4:00 P.M She was sitting 366241 Page 20 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on her buttocks with her back against the recliner facing the doorway. The resident stated she was trying to get up. The resident was assisted into wheelchair and staff brought her into lobby to better monitor. Resident needs frequent monitoring and visual checks. The resident was not seated in the common area to monitor activity per the 05/25/23 post fall intervention. Interview on 07/03/23 at 7:34 P.M. with Director of Nursing #93 verified the resident was not seated in the common area per 05/25/23 fall intervention and fell 07/02/23 from recliner while in room. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 21 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to ensure oxygen equipment was maintained in a sanitary manner and orders were obtained for the use of oxygen therapy. This affected three (Residents #25, #31, and #36) of three residents reviewed for oxygen. Residents Affected - Few Findings include: 1. Review of Resident #36's medical record revealed a 04/28/23 admission with diagnoses including moderate protein calorie malnutrition, wedge compression fracture of thoracic vertebrae, dementia, Alzheimer's, Vitamin D deficiency, diverticuli of intestines, depression, anemia, hypertension, pneumonia, muscle weakness, dysphagia, irritable bowel syndrome, osteoarthritis, and abnormal findings in lung field. Review of the 05/05/23 admission Minimum Data Set (MDS) revealed the resident was severely impaired for daily decision making, required limited assist of two for bed mobility, extensive assist of two for transfers, one person physical assist for walking, extensive assist of two for dressing, toilet use and limited assist of one for personal hygiene. The resident had a fall with fracture prior to admission. The resident was diagnosed with pneumonia 05/26/23. Review of the physician orders revealed there was not an order for oxygen therapy. Observation on 06/30/23 at 1:50 P.M. revealed the resident had an oxygen condenser in her room. The nasal cannula attached was undated and on the floor. There was not a bag attached to the condenser to store the nasal cannula. There was not an oxygen in use sign on the door. Interview on 06/30/23 at the time of the observation with State Tested Nurse Aide (STNA) #108 verified the resident's nasal cannula was on the floor and undated. STNA #108 verified there was not a bag located in the room to store the cannula for sanitation. Interview on 07/03/23 at 7:34 P.M. with Director of Nursing (DON) #93 verified the resident was on oxygen without a physician order. The DON verified the facility has oxygen in use signs but do not always post them on the resident doors. Review of the facility's Oxygen Therapy policy (dated 03/18/15) included to contact the attending physician and obtain order when necessary. Post oxygen in use signs on the door. 2. Review of Resident #25's medical record revealed the resident was admitted [DATE] with diagnoses including depression, unspecified neck injury, pneumonia, hypothyroidism, hyperlipidemia, polyneuropathy, muscle wasting and atrophy, chronic obstructive pulmonary disease, congestive heart failure, paroxysmal atrial fibrillation, hypertension, fibromyalgia, irritable bowel syndrome, anxiety disorder, gastroesophageal reflux disease, chronic gastric ulcer, anemia, nicotine dependence and hemorrhoids. Review of the Quarterly 05/03/23 MDS Assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of two for bed mobility,transfers,walk with assist 366241 Page 22 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0695 Level of Harm - Minimal harm or potential for actual harm of two, toileting, limited assist of one for dressing, extensive assist of one for personal hygiene. There were no falls since last assessment. The resident was on oxygen therapy. Physician orders included a 01/01/23 order for oxygen at three liters per minute .per nasal cannula continuous. Residents Affected - Few Observation on 06/30/23 at 1:43 P.M. revealed the resident was sitting in her recliner with oxygen on per nasal cannula. Observation of the tubing revealed the extender tubing was dated 05/02/23. Interview on 07/03/23 at 7:34 P.M. with Director of Nursing (DON) #93 verified the resident had extender tubing dated 05/02/23 and Registered Nurse (RN) #92 spoke to the oxygen representative about changing the extender sets when he changes out the cannula and nebulizers. 3. Review of Resident #31's medical record revealed a 01/16/21 admission with diagnoses including angina pectoris, bronchitis, pneumonia, muscle wasting/atrophy, paroxysmal atrial fibrillation, gastroesophageal reflux disease, hypertension, rheumatoid arthritis, renal dialysis, anemia, depression, atherosclerotic heart disease, chronic obstructive pulmonary disease, sleep apnea, type 2 diabetes, end stage renal disease and hyperkalemis. The resident had an order for oxygen at 3 Liters per minute per nasal cannula. Review of the 05/19/23 quarterly MDS revealed the resident was independent for daily decision making, uses a walker and had active range of motion times five days. The resident was independent for bed mobility, transfers, dressing, toilet use, personal hygiene and walking in room with supervision. The resident was on oxygen therapy. Observation on 06/30/23 at 1:31 P.M. revealed the resident was in a recliner with oxygen on per nasal cannula. Observation of the tubing revealed the extender tubing was dated 05/02/23. Interview on 07/03/23 at 7:34 P.M. with DON #93 verified the resident had extender tubing dated 05/02/23 and RN #92 spoke to the oxygen representative about changing the extender sets when he changes out the cannula and nebulizers. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 23 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview the facility failed to ensure Resident #38 was free from a significant medication error when the resident did not receive diabetic injections, Novolog Insulin, as ordered by the physician. This affected one resident (#38) of three residents reviewed for change in condition. Residents Affected - Few Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility from home on [DATE]. Resident #38 had diagnoses including chronic obstructive pulmonary disease, thoracic thoracolumbar and lumbosacral intervertebral disc disorder, hypercholesterolemia, osteoarthritis, and hyperlipidemia. The resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE] with additional diagnoses that included encephalopathy, acute respiratory failure, type 1 diabetes mellitus (body does not make insulin), pneumonia, seizures, abnormal plasma proteins, altered mental state, convulsions, and hyperglycemia. Record review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #38 was independent for daily decision with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment revealed the resident was able to understand others and be understood, he had no behaviors. Resident #38 required limited assistive of two staff for bed ability, extensive assistant of two staff to transfer, assist of two staff to walk in room, limited assistance of one staff to walk in corridor, extensive assistive of two staff for dressing, extensive assistive of one staff for eating, limited assist of one staff for toilet and personal hygiene. The resident had a loss of liquids and solids from mouth when eating or drinking and coughing or choking during meals and when taking medications. The resident utilized the wheelchair. Resident #38 was occasionally incontinent of urine and always incontinent of stool. The assessment noted the resident received insulin injections seven day a week. Record review revealed from admission [DATE] through 06/05/23) Resident #38's blood sugar levels ranged from 78 mg/dl to 482/dl, generally in the 200 mg/dl to 350 mg/dl range. On 06/05/23 Medical Director (MD) #134 ordered Novolog (insulin) coverage (a rapid acting insulin) via a sliding scale four times a day for blood sugars using a formula for blood glucose levels greater than 150. For blood glucose levels above 150, staff would divide the result by 30 and minus 3 to determine the number of Novolog units to administered subcutaneously. The sliding scale coverage was to be used following blood glucose monitoring daily at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 10:00 P.M. Review of the Medication Administration Record (MAR) revealed on 06/05/23 at 10:00 P.M. Resident #38's blood sugar was 278 and four units of Novolog coverage was administered. This was noted to be an error as the resident should have been administered six units of insulin. At 6:00 A.M. on 06/06/23 the resident's blood sugar was 209. The resident was administered three units of insulin and the dosage should have been four units. At 11:00 A.M. on 06/06/23 the resident's blood sugar was 171 and the resident was administered six units of insulin. This was also an error as the dosage should have been three units. On 06/06/23 at 10:00 P.M. the resident's blood sugar was 168 and the resident should have been administered three units of insulin; however, there was no documentation of the resident receiving any insulin coverage. On 06/07/23 at 6:00 A.M. the resident was administered four units of insulin for a blood sugar of 176. This was an error as the resident should have been administered 366241 Page 24 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0760 three units of insulin. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed Medical Director (MD) #134 visited and met the resident for the first time on 06/08/23 at approximately 3:40 P.M. Review of the 06/08/23 physician progress note included diabetes mellitus has been sub-optimally controlled, and medications would be adjusted. Residents Affected - Few Review of the meal intake record revealed Resident #38 did not eat breakfast on 06/08/23 and ate 76-100 percent for both lunch and supper. Review of the medication administration record (MAR) revealed on 06/08/23 at 10:00 P.M. the resident's blood sugar was 290 and the resident was administered 10 units Novolog insulin, which was an error as the resident should have been administered seven units. Review of Resident #38's nurse's notes revealed on 06/09/23 a 5:44 A.M. late entry note entered by Licensed Practical Nurse (LPN) #94 revealed at 2:17 A.M. STNA #131 reported to this nurse the resident was cold and clammy. Upon entering resident's room, resident was breathing heavily with vomit on right side of bed. When this nurse called out resident's name, resident did not respond. The LPN walked closer to resident's bedside called out again with no response. Began sternal rubs with no response. This nurse ran to cart grabbed blood pressure cuff, pulse oximeter and glucometer. Blood pressure was 122/77 millimeters of mercury (mm/Hg), temperature was 98.0 degrees Fahrenheit, respirations 22 per minute, pulse 94 beats per minute, oxygen saturation 97 percent on room air. Blood glucose monitoring was 32 mg/dl . Glucagon gel administered and blood glucose increased to 37 mg/dl. 911 called at 2:20 A.M. to transport resident to emergency room for evaluation and treatment. This nurse stayed with resident at bedside until emergency medical technicians (EMT) arrived at 2:33 A.M. EMT immediately started an intravenous line and Dextrose was administered. The resident's blood glucose increased to 302 mg/dl. Review of the Fire Department (EMT) record for this incident revealed they received the call at 2:21 A.M., arrived at 2:29 A.M. and found the resident unresponsive. EMTs placed an intravenous line and administered 25 grams of glucose intravenously. At 2:40 A.M. the resident's blood sugar was 302. A non-rebreather mask was placed at 12 liters of oxygen per minute. Response improved but the resident was still unresponsive. Skin was clammy and diaphoretic. The resident was pale. Pupils 3 millimeters (mm) and sluggish. Departed facility at 2:41 A.M., arrived at the emergency room 2:46 A.M. and transferred to emergency room cart 2:48 A.M. Resident #38 was discharged back to the facility on [DATE] with diagnoses including change in mental status, elevated troponin levels, hyperglycemia, pneumonia, acute respiratory failure, and seizure. Additional diagnoses included provoked seizure, uncontrolled type 1 diabetes mellitus with hypoglycemia. Interview on 06/27/23 at 5:17 P.M. with Director of Nursing #93 revealed the facility did not do an investigation into what factors may had lead to the hypoglycemia (low blood sugar) and did not identify the medication errors. Interview on 06/27/23 at 5:52 P.M. with RN #96 revealed she was on duty 06/08/23 from 6:00 P.M. until 10:00 P.M. The RN stated she obtained the resident's blood sugar at 9:30 P.M. and it was 290 mg/dl and she administered the sliding scale insulin coverage of 10 units of Novolog insulin. At the time of the interview, RN #96 was unaware she had not administered the correct dose of insulin and had given the resident three units of insulin too much. The RN concluded with the formula blood sugar 366241 Page 25 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0760 divided by 30 minus three she must not have subtracted the three units. Level of Harm - Minimal harm or potential for actual harm Review of the email from the Administrator on 06/29/23 at 1:06 P.M. revealed Director of Nursing #93 confirmed the additional errors in the amount of insulin coverage the resident received as noted above. Residents Affected - Few The facility Insulin Administration policy, was updated on 06/28/23 to include to double check the insulin dosage before drawing the dose into the syringe. This deficiency represents non-compliance investigated under Complaint Number OH00143538. 366241 Page 26 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to maintain accurate medication administration records. This affected 30 (Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #25, #30, #33, #36, #38, #39, #41, #43, and #44) of 41 individuals in the facility on 05/20/23. Findings include: 1. Review of facility documentation revealed on the night shift of 06/19/23 into 06/20/23 the night shift medications scheduled to be administered 6:00 P.M. until 6:30 A.M. were not signed off on the electronic Medication Administration Records as being administered as ordered. There was no paper record of the medications being administered as ordered. Review of the medications due to be administered on night shift 06/19/23 into 06/20/23 revealed Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #25, #30, #33, #36, #38, #39, #41, #43, and #44 did not have medications signed off as being administered. Interview on 06/26/23 at 11:35 A.M. with Director of Nursing (DON) #93 revealed the registered nurse on duty was not able to access the point click care system therefore she reviewed the resident's medical records to read the orders and determine what medications to administer. The registered nurse did not document on paper what she administered. The facility did not provide a policy on documenting medication administration. 2. Review of Resident #20's medical record revealed a 05/09/23 admission with diagnoses including depression, Alzheimer's disease, insomnia, dementia, hypothyroidism, Vitamin D deficiency, hyperlipidemia, anxiety, paralysis of vocal cords and larynx bilaterally, acute and chronic respiratory failure with hypoxia, gastroesophageal reflux disease, osteoarthritis of left shoulder, cervical disc disorder with myelopathy, low back pain, fibromyalgia, post laminectomy syndrome, long term use of opiate, tracheostomy status, right artificial hip, bilateral artificial knees, and bursitis of left shoulder. The admission skin assessment revealed no documentation of a pressure ulcer. There were no measurements or description of a skin impairment for the ordered dressing to right buttock. Review of the treatment sheets revealed starting 05/24/23 the nurses were signing off an order to cleanse coccyx with normal saline, apply alginate and foam dressing daily; and cleanse right buttock with normal saline, apply collagan particles and foam dressing Tuesday, Thursday and Saturday. The resident only had one open area not two. The daily alginate dressing was signed off as changed daily except for 05/29/23, 06/05/23, 06/12/23, 06/15/23 and 06/25/23. The three times a week collagen dressing was signed off as ordered except for 06/01/23, 06/06/23, and 06/10/23. Interview on 06/26/23 at 6:02 P.M. with DON #93 verified the medical record was inaccurate since there was not an assessment of the resident's pressure ulcer between 05/09/23 and 05/24/23. DON #93 further verified the nurses were signing off two treatments for the same pressure ulcer. 366241 Page 27 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of Resident #41's medical record revealed a 5/25/22 admission with diagnoses including Alzheimer's disease, idiopathic peripheral autonomic neuropathy, depression, restlessness and agitation, anxiety disorder, dementia with behavioral disturbance, dysphagia, psychosis, hyperlipidemia, hypertension, psychotic disorder with delusions, and Parkinson's disease. Review of the resident's pressure ulcer assessments included a left lateral lower extremity unstageable pressure ulcer developed 04/14/23. On 06/06/23 the ulcer measured 3.8 cm x 3.2 cm x 0.1 with moderate serous drainage. Dakins 0.125 percent moist gauze and a dry dressing was ordered daily on 05/23/23. On 06/07/23 an order was written to cleanse left lateral ankle with normal saline, alginate and foam dressing daily and as needed. The dressing was not documented as applied 06/14/23. The Dakins dressing was not discontinued and the nurses were signing on the treatment sheets they were applying both dressings to the same area from 06/07/23 until 06/20/23. A right lower extremity suspected deep tissue injury developed 04/14/23. The ulcer measured 1.0 cm x 1.0 cm x 0.05 cm on 06/06/23 and was left open to air. On 06/07/23 an order for foam to the right lateral ankle wound three times a week every Tuesday, Thursday and Saturday was ordered. The leave open to air order was not discontinued. The nurses were signing off they were changing the dressing and leaving the area open to air. The foam dressing was not documented as applied on 06/10/23. The treatment sheet had leave area opened to air signed off as completed from 06/07/23 through 06/20/23 at the same time the foam dressing was documented as being applied. There was not a weekly pressure ulcer assessment completed on 06/13/23. Interview on 06/26/23 at 2:59 P.M. with DON #93 verified she was unable to determine which dressing was being applied to the left lower ankle. The DON verified the staff was signing off contradictory orders for the resident's pressure ulcers making an inaccurate medical record. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 28 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0843 Level of Harm - Minimal harm or potential for actual harm Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Based on record review and interview, the facility failed to obtain a transfer agreement with a hospital. This had the potential to affect all the residents in the facility. The facility census was 38. Residents Affected - Many Findings include: Review of facility documentation including contracts and transfer agreements revealed the facility did not obtain a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. The agreement was to ensure timely admission to the hospital when resident transfer is medically appropriate as determined by the attending physician or, in an emergency situation, by another practitioner. An email from the Administrator dated 07/06/23 at 3:38 P.M. verified he did not locate a transfer agreement. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 29 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assessment and Assurance (QAA) meetings sign in sheets, policy review, and interview, the facility failed to ensure the Medical Director or his designee attended quarterly meetings. This had the potential to affect all 38 residents in the facility. Residents Affected - Many Findings include: Review of the QAA meeting attendance signature sheets revealed there was not a physician present at the 01/27/23 first quarter meeting. Interview on 07/03/23 at 7:19 P.M. with Director of Nursing (DON) #93 verified there was not a physician present at the quarterly QAA meeting in January 2023. Review of the facility Quality Assurance and Performance Improvement (QAPI) policy (undated) did not include the Medical Director/physician was to attend meetings quarterly as regulated. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 30 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review and interview, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff. This had the potential to affect all the residents in the facility. The census was 38. Residents Affected - Many Findings include: Review of State Tested Nurse Aides (STNA) #98, #108 and #117's personnel records revealed there was no evidence of communication, Quality Assurance and Performance Improvement, ethics, or behavioral health training. Interview on 07/03/23 at 4:10 P.M. with Director of Nursing (DON) #93 revealed they have not started the new trainings to meet the Phase III requirements. Review of an email dated 07/06/23 at 3:52 P.M. from the Administrator verified they do not provide the Phase III training requirements. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 31 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on personnel record review, review of the Facility Assessment, email review, and interview, the facility failed to provide effective communications training for direct care staff. This had the potential to affect all 38 residents in the facility. Findings include: Review of the facility's Facility Assessment Tool dated 03/2023 included communication, effective communication for direct care staff, was included in their staff training, education and competencies. Review of personnel records for State Tested Nurse Aides (STNA) #98, #108 and #117 revealed communication training was not included in the new hire orientation training or annually. Interview on 07/03/23 at 4:10 P.M. with Director of Nursing #93 revealed they do not provide the communication training. Review of an email on 07/06/23 at 3:40 P.M. from the Administrator verified the type of communication training described in the regulation was not included in their Inservice. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 32 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on personnel record review, policy review, email review, and interview, the facility failed to include in its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program. This had the potential to affect all 38 residents in the facility. Findings include: Review of the facility Quality Assurance and Performance Improvement (QAPI) policy (undated) did not include mandatory staff training. Review of personnel records of State Tested Nurse Aides (STNA) #98, #108 and #117's revealed QAPI training was not included as part of the facility's new hire or annual training. Interview on 07/03/23 at 4:10 P.M. with Director of Nursing (DON) #93 revealed the facility does not provide the new QAPI training as required. Review of an email dated 07/06/23 at 3:42 P.M. from the Administrator verified the facility was not doing annual training for QAPI. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 33 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, email review, and interview, the facility failed to provide ethics training to all staff. This had the potential to affect all 38 residents in the facility. Residents Affected - Many Findings include: Review of personnel records of State Tested Nurse Aides (STNA) #98, #108 and #117's revealed ethics training was not included in the new hire orientation training or annually. Interview on 07/03/23 at 4:10 P.M. with Director of Nursing (DON) #93 revealed the facility does not offer the new requirement for ethics training. Review of an email dated 07/06/23 at 3:52 P.M. from the Administrator verified they do not offer ethics training. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 34 of 35 366241 07/07/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of the Facility Assessment, personnel record review, email review, and interview, the facility failed to provide behavioral health training on hire. This had the potential to affect all 38 residents in the facility. Findings include: Review of the facility's Facility assessment dated 03/2023 included under staff training, education and competencies training would be provided for caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post traumatic stress disorder, and implementing non-pharmacological interventions. Review of State Tested Nurse Aides (STNA) #98, #108 and #117's personnel records revealed there was no evidence of behavioral health training. Interview on 07/03/23 at 4:10 P.M. with Director of Nursing (DON) #93 revealed they have not started the new trainings to meet the Phase III requirements. Review of an email dated 07/06/23 at 3:52 P.M. from the Administrator verified they do not provide the Phase III requirements. This deficiency is an incidental finding to Complaint Number OH00143538. 366241 Page 35 of 35