Health inspection·July 21, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, review of an incident report and witness statements, review of hospital records, policy review and interview, the facility failed to report an injury of unknown origin pending a thorough investigation. This affected one resident (Resident #14) of three residents reviewed for injuries of unknown origin. The census was 44. Findings include: Review of Resident #14's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, vitamin D deficiency, atrial fibrillation, osteoarthritis of the left knee, depression, iron deficiency anemia and legal blindness. A nursing incident note dated 07/08/23 at 3:40 P.M. indicated after Resident #14 was laid down after lunch, a state tested nursing assistant noticed an abnormality and reported it to the nurse. Upon observation, a deformity was noted to the left thigh region with Resident #14 complaining of pain during the assessment. Resident #14 was unable to provide a statement related to causative factors. The physician was notified and stat x-rays were ordered to rule out osteoporotic fractures and management. The x-ray company was notified. A nursing note dated 07/08/23 at 4:25 P.M. indicated a call was received from the x-ray technician who stated the x-ray would not be done until 9:00 to 10:00 A.M. due to her being in a different region. The physician was updated and gave approval to wait as long as Resident #14 stayed in bed and was in no significant pain. A nursing note dated 07/08/23 at 7:05 P.M. indicated Resident #14's leg was not stable when moved and had a large curve in the thigh area indicating a femur fracture. Resident #14 screamed out in pain when staff attempted to reposition her for assessment and to provide care. The note indicated hospice was notified Resident #14 was going to be sent to the emergency room (ER) for further evaluation and stabilization of the leg. The physician was notified and was in agreement. 911 emergency services was notified for transport to the ER. A nursing note dated 07/09/23 at 3:20 A.M. indicated Resident #14 was admitted to the hospital for a left femur fracture. The plan was to assess Resident #14's need for surgery to stabilize her leg. Resident #14 was to see the cardiologist and anesthesia to consult about possible surgery. Review of an Incident and Accident Report dated 07/08/23 revealed at 1:30 P.M. a deformed appearance was observed to the left thigh with Resident #14 complaining of pain. Five witness statements were documented on the back of the incident report. Three of the statements revealed the staff were not involved in Resident #14's care that day. State Tested Nursing Assistant (STNA) #100 revealed Resident #14 was up in her chair. When she and STNA #110 put Resident #14 in bed she noticed Resident #14's leg was not normal. STNA #110 wrote that as she and STNA #100 were placing Resident #14 in bed for a nap after lunch they noticed the left upper thigh was deformed and Resident #14 was experiencing pain. The information was reported to the registered nurse on duty at 1:30 P.M. There was no further investigation documented. Page 1 of 9 366241 366241 07/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of hospital records revealed a computed tomography (CT) report dated 07/08/28 which indicated the clinical indication for the test was an injury or trauma; traumatic fracture. The findings indicated bones were demineralized which might limit evaluation. A displaced angulated distal left femoral shaft fracture was noted. A x-ray report on 07/09/23 indicated there was interval fixation of follow-up spiral fracture of the left femur by means of a intramedullary rod and multiple screws. A hospital history and physical dated 07/09/23 indicated Resident #14 was minimally arousable and not oriented but reacted to pain. Surgical repair was recommended to alleviate pain and discomfort. There was no indication the fracture was believed to be pathological in nature (a break is called a pathologic fracture when force or impact didn't cause the break to happen). After Resident #14 was readmitted to the facility, a diagnosis of pathological fracture of the left femur was added on 07/12/23 however, there was no evidence the fracture was identified as pathological during the resident's hospital stay. On 07/19/23 at 11:55 A.M., Registered Nurse (RN) #120 stated there was no Facility Reported Incident submitted because the physician had indicated without a known trauma it was a pathological fracture. RN #120 acknowledged the interviews completed were of day shift staff only. On 07/20/23 at 3:40 P.M., the Administrator stated he could not answer whether a facility reported incident should have been completed since the verbal reports he received from staff did not include the information shared with the surveyor. Review of the facility's Resident Incidents policy revealed if an incident was an injury of unknown origin and the injury could not be determined through investigation then a Self Reported Incident would be submitted by the Administrator. Review of the facility's Resident Neglect, Abuse, Misappropriation of Property and Injuries of Unknown Origin policy, dated March 2022, revealed injuries of unknown origin were classified as injuries in which the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Neglect was defined as recklessly failing to provide a resident with any treatment, care, goods or service necessary to maintain the health or safety of the resident when the failure resulted in serious physical harm to the resident. All accusations of neglect would be taken seriously and fully investigated. If the investigation of an unknown injury indicated that abuse may have occurred, the abuse policy should be followed. If the investigation of an unknown injury concluded with no suspicion and no allegation, the investigation would be concluded. This deficiency represents non-compliance investigated under Complaint Number OH00144427. 366241 Page 2 of 9 366241 07/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of an incident report and witness statements, review of hospital records, policy review and interview, the facility failed to thoroughly investigate an injury of unknown origin. This affected one resident (Resident #14) of three residents reviewed for injuries of unknown origin. The census was 44. Residents Affected - Few Findings include: Review of Resident #14's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, vitamin D deficiency, atrial fibrillation, osteoarthritis of the left knee, depression, iron deficiency anemia and legal blindness. A nursing incident note dated 07/08/23 at 3:40 P.M. indicated after Resident #14 was laid down after lunch, a state tested nursing assistant noticed an abnormality and reported it to the nurse. Upon observation, a deformity was noted to the left thigh region with Resident #14 complaining of pain during the assessment. Resident #14 was unable to provide a statement related to causative factors. The physician was notified and stat x-rays were ordered to rule out osteoporotic fractures and management. The x-ray company was notified. A nursing note dated 07/08/23 at 4:25 P.M. indicated a call was received from the x-ray technician who stated the x-ray would not be done until 9:00 to 10:00 A.M. due to her being in a different region. The physician was updated and gave approval to wait as long as Resident #14 stayed in bed and was in no significant pain. A nursing note dated 07/08/23 at 7:05 P.M. indicated Resident #14's leg was not stable when moved and had a large curve in the thigh area indicating a femur fracture. Resident #14 screamed out in pain when staff attempted to reposition her for assessment and to provide care. The note indicated hospice was notified Resident #14 was going to be sent to the emergency room (ER) for further evaluation and stabilization of the leg. The physician was notified and was in agreement. 911 emergency services was notified for transport to the ER. A nursing note dated 07/09/23 at 3:20 A.M. indicated Resident #14 was admitted to the hospital for a left femur fracture. The plan was to assess Resident #14's need for surgery to stabilize her leg. Resident #14 was to see the cardiologist and anesthesia to consult about possible surgery. Review of an Incident and Accident Report dated 07/08/23 revealed at 1:30 P.M. a deformed appearance was observed to the left thigh with Resident #14 complaining of pain. Five witness statements were documented on the back of the incident report. Three of the statements revealed the staff were not involved in Resident #14's care that day. State Tested Nursing Assistant (STNA) #100 revealed Resident #14 was up in her chair. When she and STNA #110 put Resident #14 in bed she noticed Resident #14's leg was not normal. STNA #110 wrote that as she and STNA #100 were placing Resident #14 in bed for a nap after lunch they noticed the left upper thigh was deformed and Resident #14 was experiencing pain. The information was reported to the registered nurse on duty at 1:30 P.M. There was no further investigation documented. Review of hospital records revealed a computed tomography (CT) report dated 07/08/28 which indicated the clinical indication for the test was an injury or trauma; traumatic fracture. The findings indicated bones were demineralized which might limit evaluation. A displaced angulated distal left femoral shaft fracture was noted. A x-ray report on 07/09/23 indicated there was interval fixation of follow-up spiral fracture of the left femur by means of a intramedullary rod and multiple screws. A hospital history and physical dated 07/09/23 indicated Resident #14 was minimally arousable and not oriented by reacted to pain. Surgical repair was recommended to alleviate pain and discomfort. There was no indication the fracture was believed to be pathological in nature (a break is called a pathologic fracture when force or impact didn ' t cause the break to happen). After Resident #14 was 366241 Page 3 of 9 366241 07/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few readmitted to the facility, a diagnosis of pathological fracture of the left femur was added to the resident's medical record despite no evidence or documentation from the hospital records indicating the fracture was pathological in nature. During interviews on 07/19/23 at 11:34 A.M. and 3:58 P.M., STNA #130 (who worked night shift on 07/07/23) stated she assisted STNA #140 to provide last rounds the morning of 07/08/23. STNA #130 stated staff generally turned Resident #14 onto her left side then swung her legs around to the side of the bed then transferred her to the wheelchair where they would put her shirt on. This was related to Resident #14's contractures. STNA #140 raised Resident #14's trunk in an attempt to don her shirt without turning her or sitting her up as staff usually did. STNA #130 stated she and STNA #140 both heard a crack and she had Licensed Practical Nurse (LPN) #150 assess Resident #14. STNA #130 stated staff always used two assists to transfer Resident #14 into her chair but that morning STNA #140 transferred her alone. On 07/19/23 at 11:55 A.M., Registered Nurse (RN) #120 stated there was no further investigation or attempts to interview the night shift regarding the fracture because the physician had said with no record of trauma it was a pathological fracture. Review of the facility's Resident Incidents policy revealed if an incident was an injury of unknown origin and the injury could not be determined through investigation then a Self Reported Incident would be submitted by the Administrator. Review of the facility's Resident Neglect, Abuse, Misappropriation of Property and Injuries of Unknown Origin policy, dated March 2022, revealed injuries of unknown origin were classified as injuries in which the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Neglect was defined as recklessly failing to provide a resident with any treatment, care, goods or service necessary to maintain the health or safety of the resident when the failure resulted in serious physical harm to the resident. All accusations of neglect would be taken seriously and fully investigated. If the investigation of an unknown injury indicated that abuse may have occurred, the abuse policy should be followed. If the investigation of an unknown injury concluded with no suspicion and no allegation, the investigation would be concluded. This deficiency represents non-compliance investigated under Complaint Number OH00144427. 366241 Page 4 of 9 366241 07/21/2023 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 observations, medical record review, review of incident reports, and interview, the facility failed to provide supervision to prevent elopement affecting one resident (Resident #1) of three residents reviewed for accidents. The facility also failed to implement fall prevention interventions to prevent falls affecting two residents (Residents #1 and #14) of three residents reviewed for accidents and failed to appropriately transfer one resident (Resident #14) of three residents reviewed for accidents. The census was 44. Findings include: 1. Review of Resident #1's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, depression, and cognitive communication deficit. a. Review of a Wandering Risk Scale assessment dated [DATE] indicated Resident #1 was at high risk for wandering. Risk factors included the inability to follow instructions, ambulatory status, a history of wandering, and a medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength. Instructions on the assessment indicated re-evaluation should be completed at 72 hours and one month later. The assessment was locked on 02/06/23 without re-evaluation at 72 hours. Review of a nursing note dated 02/01/23 at 6:43 P.M. revealed Resident #1 ambulated ad lib (at liberty). A wanderguard was applied due to wandering. Review of a nursing note dated 02/20/2023 at 1:08 P.M. indicated at 9:30 A.M. Resident #1's power of attorney (POA) was notified Resident #1 had a fall outside with an open area to the upper lip with bleeding. Skin tears were noted to both knees. Review of an incident report dated 02/20/23 at 11:01 A.M. indicated Licensed Practical Nurse (LPN) #160 was notified by staff Resident #1 was observed outside. LPN #160 observed Resident #1 pass the 400 hall door going toward the front of the building. LPN #160 indicated she ran outside and up to Resident #1. When LPN #160 called Resident #1's name she tripped and fell forward landing on her hands and hitting her mouth. Resident #1 was assisted inside the building and assessed for injuries. Resident #1 was confused and looking for her car to leave. The incident report was silent to how long Resident #1 was outside, when she was last seen or how she exited the building without her wanderguard alerting staff. During an interview on 07/19/23 at 4:30 P.M., Registered Nurse (RN) #170 (a co-Director of Nursing/co-DON) stated only the front door was alarmed with use of the wanderguard. It was determined Resident #1 exited the building through the 200 hall door without the door sounding. The facility determined the 200 hall door was not latching correctly and had it repaired the same day. RN #170 was asked if it had been determined how long Resident #1 had been outside unattended and stated the entire incident report had not been provided so she would look for additional information. No information was provided as of 07/20/23 at 10:18 A.M. During an interview on 07/20/23 at 10:18 A.M., RN #120 (a co-DON) was asked if any additional information was located regarding a more thorough investigation/witness statements from staff when 366241 Page 5 of 9 366241 07/21/2023 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 Resident #1 left the building accompanied by staff on 02/20/23. RN #120 stated she would have to contact RN #170. RN #120 verified the back door on the 200 hall led to a driveway which was not enclosed. RN #120 stated she could not recall what the weather was like on 02/20/23. RN #120 stated she thought the facility did door audits after the incident and would search for supportive documentation. Review of the facility's Elopement policy, dated 03/18/15, indicated investigations were to be completed for actual elopement occurrences. Staff were to determine the means of elopement and risk for repeated actions, make immediate changes to safeguard residents at risk for elopement, management was to notify the family and physician, and an incident report was to be completed and findings reported to the appropriate committees/personnel. On 07/20/23 the Administrator indicated there was no further information/investigation to share. The Administrator stated the wanderguard door and key pad doors were monitored a minimum of monthly as part of the facility's preventative maintenance program. b. Review of a plan of care initiated 02/03/23 indicated Resident #1 was at risk for falls related to vertigo, need for assistance with activities of daily living, cognitive impairment and wandering. An intervention dated 02/03/23 indicated a visual reminder was to be placed in the room to remind Resident #1 to utilize the call light for assistance. An intervention for dycem to the chair in the room was initiated 02/25/23. A fall risk assessment dated [DATE] revealed Resident #1 was at high risk of falling. Risk factors included a history of falls, co-morbidities (multiple diagnoses), assistance needed for ambulation, unsteady gait and over-estimating or forgetting limits. On 07/19/23 at 1:09 P.M., State Tested Nursing Assistant (STNA) #180 was observed transferring Resident #1 from the wheelchair to the bed with assistance of another staff member. LPN #160 entered the room at the time of transfer and verified there was no dycem in the chair and no signs or visual reminders posted to remind Resident #1 to use the call light for assistance. 2. Review of Resident #14's medical record revealed diagnoses including Alzheimer's disease, anxiety disorder, vitamin D deficiency, atrial fibrillation, osteoarthritis of the left knee, depression, iron deficiency anemia and legal blindness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 was severely cognitively impaired and required extensive assist of two for bed mobility and transfers. a. A nursing incident note dated 07/08/23 at 3:40 P.M. indicated after Resident #14 was laid down after lunch, a state tested nursing assistant noticed an abnormality and reported it to the nurse. Upon observation, a deformity was noted to the left thigh region with Resident #14 complaining of pain during the assessment. Resident #14 was unable to provide a statement related to causative factors. The physician was notified and stat x-rays were ordered to rule out osteoporotic fractures and management. The x-ray company was notified. A nursing note dated 07/08/23 at 4:25 P.M. indicated a call was received from the x-ray technician who stated the x-ray would not be done until 9:00 to 10:00 A.M. due to her being in a different region. The physician was updated and gave approval to wait as long as Resident #14 stayed in bed and was in no significant pain. A nursing note dated 07/08/23 at 7:05 P.M. indicated Resident #14's leg was not stable when moved and had a large curve in the thigh area indicating a femur fracture. Resident #14 screamed out in pain when staff attempted to reposition her for assessment and to provide care. The note indicated hospice was notified Resident #14 was going to be sent to the emergency room (ER) for further evaluation and stabilization of the leg. The 366241 Page 6 of 9 366241 07/21/2023 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 physician was notified and was in agreement. 911 emergency services was notified for transport to the ER. A nursing note dated 07/09/23 at 3:20 A.M. indicated Resident #14 was admitted to the hospital for a left femur fracture. The plan was to assess Resident #14's need for surgery to stabilize her leg. Resident #14 was to see the cardiologist and anesthesia to consult about possible surgery. Review of an Incident and Accident Report dated 07/08/23 revealed at 1:30 P.M. a deformed appearance was observed to the left thigh with Resident #14 complaining of pain. Five witness statements were documented on the back of the incident report. Three of the statements revealed the staff were not involved in Resident #14's care that day. State Tested Nursing Assistant (STNA) #100 revealed Resident #14 was up in her chair when she and STNA #110 put Resident #14 in bed and she noticed Resident #14's leg was not normal. STNA #110 wrote that as she and STNA #100 were placing Resident #14 in bed for a nap after lunch they noticed the left upper thigh was deformed and Resident #14 was experiencing pain. The information was reported to the registered nurse on duty at 1:30 P.M. There was no further investigation documented. Review of hospital records revealed a computed tomography (CT) report dated 07/08/28 which indicated the clinical indication for the test was an injury or trauma; traumatic fracture. The findings indicated bones were demineralized which might limit evaluation. A displaced angulated distal left femoral shaft fracture was noted. A x-ray report on 07/09/23 which indicated there was interval fixation of follow-up spiral fracture of the left femur by means of a intramedullary rod and multiple screws. A hospital history and physical dated 07/09/23 indicated Resident #14 was minimally arousable and not oriented by reacted to pain. Surgical repair was recommended to alleviate pain and discomfort. There was no indication the fracture was believed to be pathological in nature (A break is called a pathologic fracture when force or impact didn't cause the break to happen). During interviews on 07/19/23 at 11:34 A.M. and 3:58 P.M., STNA #130 (who worked night shift on 07/07/23) stated she assisted STNA #140 to provide last rounds the morning of 07/08/23. STNA #130 stated staff generally turned Resident #14 onto her left side then swung her legs around to the side of the bed then transferred her to the wheelchair where they would put her shirt on. This was related to Resident #14's contractures. STNA #140 raised Resident #14's trunk in an attempt to don her shirt without turning her or sitting her up as staff usually did. STNA #130 stated she and STNA #140 both heard a crack and she had Licensed Practical Nurse (LPN) #150 assess Resident #14. STNA #130 stated staff always used two assists to transfer Resident #14 into her chair but that morning STNA #140 transferred her alone. During an interview on 07/19/23 at 6:06 P.M., LPN #150 stated the morning of 07/08/23, STNA #130 stated STNA #140 was panicking because she heard a crack when she lifted Resident #14's trunk to apply her shirt. LPN #150 stated STNA #130 reported it was not unusual for Resident #14's back to crack when she got up. LPN #150 stated she assessed Resident #14 and checked range of motion with no injury noted and no complaints of pain. LPN #150 stated she offered multiple times to assist STNA #130 to transfer Resident #14 into the wheelchair as she saw how freaked out STNA #140 was at the time but her offers were declined. LPN #150 stated STNA #130 later reported STNA #140 transferred Resident #14 by herself. During an interview on 07/20/23 at 10:48 A.M., STNA #100 stated on 07/08/23 Resident #14 was up in the wheelchair when she arrived for her shift and stayed up until after lunch. STNA #100 stated she was with STNA #110 and when they put Resident #14 to bed they identified the deformity and reported it. Resident #14 would have been transferred to the chair by night shift. 366241 Page 7 of 9 366241 07/21/2023 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 b. Review of Resident #14's plan of care revealed she was at risk for falls related to impaired balance, blindness, and decreased safety awareness. One of the interventions was to place dycem in the wheelchair. An associated order written 10/13/22 indicated the placement of the dycem was to be monitored every shift. Review of a fall risk assessment dated [DATE] indicated Resident #14 was at moderate risk of falling. Risk factors included co-morbidities and over-estimating or forgetting limits. On 07/19/23 at 6:27 P.M., STNA #130 and STNA #190 were observed transferring Resident #14 from her wheelchair to her bed. No dycem was observed in the wheelchair. This was verified by STNA #190. This deficiency represents non-compliance investigated under Complaint Number OH00144427 and an example of continued non-compliance from the survey 07/07/23. 366241 Page 8 of 9 366241 07/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of an incident report, review of personnel information, observations and interview, the facility failed to ensure an employee, who was fulfilling the duties of a nursing assistant, met requirements to provide care. This affected one resident (Resident #4) of three residents reviewed for injuries of unknown origin. The census was 44. Findings include: Review of Resident #4's medical record revealed diagnoses including Alzheimer's disease and cerebrovascular disease. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had impaired short and long term memory problems and severely impaired skills for daily decision making. Resident #4 required extensive assistance of two for transfers. Review of a nursing note dated 06/27/23 at 11:40 A.M. revealed Resident #4's daughter notified the nurse of a bruise and swollen area to the middle of the forehead. Review of an incident report dated 06/27/23 at 8:30 A.M. revealed the daughter informed the nurse of the bruise around 8:15 A.M. when Resident #4 was sitting up in her chair. The incident report indicated Resident #4 required a hoyer lift for transfers. Review of a witness statement by Employee #200 (who identified herself as a Certified Nursing Assistant) revealed she assisted in getting Resident #4 up that morning for breakfast. Employee #200 indicated she noticed nothing unusual. On 07/19/23 at 12:00 P.M., Resident #4 was observed sitting in her wheelchair in her room with a fading bruise on her forehead. Resident #4's daughter was present and stated she believed the bruise was a result of being hit on the head with the hoyer lift during a transfer. Review of the qualifications of the two staff members who transferred Resident #4 on 06/27/23 revealed Employee #200 was a Certified Patient Care Technician/Assistant. There was no evidence of enrollment in a nurse aide training program or prior completion of a nurse aide training program. On 07/20/23 between 4:00 P.M. and 6:00 P.M., Human Resource Director #210 verified Employee #200 was originally hired to work in activities on 12/07/21. She began performing duties of a state tested nursing assistant on 05/26/22 but never started nurse aide training because she was planning on training as a phlebotomist. Human Resource Director #210 indicated she had researched online and believed Employee #210 met the requirements to work as a state tested nursing assistant. 366241 Page 9 of 9