Health inspection·October 2, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and review of the daily posting it was determined the facility failed to ensure accomodation of resident needs to ensure resident's call lights were answered timely. This affected four residents (#3, #9, #20, and #40) of 41 residents residing in the facility. Residents Affected - Few Findings included: Review of the daily posting dated 10/02/24 revealed the census was 41. There was one Registered Nurse (RN), two Licensed Practical Nurses (LPN), and seven State Tested Nurses' Aides (STNA) to provide direct care to the 41 residents residing in the facility. Observation on 10/02/24 at 7:31 A.M. of call lights revealed Resident #9's call light had been activated prior to the surveyor entering the unit. The call light was activated until 7:39 A.M. when a staff member answered the light. Staff were observed walking by the call light and a housekeeping staff was observed in the hallway during the eight-minute observation and no one answered Resident #9's call light. Observation on 10/02/24 at 8:00 A.M., revealed Resident #20's call light was activated. The call light was not answered until 8:21 A.M. by State Tested Nurse Aide (STNA) #173. Interview on 10/02/24 at 8:23 A.M., with Resident #9 confirmed call lights were not answered timely. The resident reported she has waited 30 minutes to an hour for staff to answer her call light. The resident reported she has chronic pain and needs to keep her pain medication on a schedule to manage her pain. The resident reported she must activate her light prior to needing pain medication due to the anticipation it would take staff awhile to respond to her call light. Interview on 10/02/24 at 8:25 A.M., with STNA #173 confirmed she was the first staff member to respond to Resident #20's call light. The STNA reported she was not sure who was assigned to that unit due to the assignment sheet was missing this morning and staff were going back and forth from both units helping each other. Interview on 10/02/24 at 12:57 P.M., with Resident #3 confirmed staff do not respond timely to call lights. The resident reported sometimes it takes up to an hour for staff to respond to her call light. Observation on 10/02/24 at 1:04 P.M., revealed Resident #3's call light was activated prior to the surveyor entering the unit. The call light was not answered until 1:12 P.M. Observation on 10/02/24 at 1:16 P.M., revealed Resident #40's call light was activated. The call Page 1 of 4 366241 366241 10/02/2024 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0558 light was not answered until 1:26 P.M. Level of Harm - Minimal harm or potential for actual harm Interview on 10/02/24 at 1:20 P.M. with LPN #153 confirmed staff do not answer call lights timely. The LPN reported staffing shortages was not the issue. The LPN reported staff either ignore the call lights or refuse to provide care to certain residents. Residents Affected - Few Interview on 10/02/24 at 1:35 P.M., with the Director of Nursing (DON) revealed staff not answering call lights timely has been an issue for a few months. The DON reported staffing shortage was not the issue for example today the facility had three nurses and seven STNA's for 41 residents and the issue seems to be staff congregate in one area. This deficiency represents non-compliance investigated under Complaint Number OH00157827. 366241 Page 2 of 4 366241 10/02/2024 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of shower schedule, and interviews the facility failed to ensure resident dependent on staff for bathing had bath preference honored. This affected three residents (#9, #22, and #43) of three records reviewed. Residents Affected - Few Findings included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including respiratory failure, paraplegia, pressure ulcer to heels and sacrum, chronic kidney disease, heart disease, chronic pain, colostomy, gastrostomy, and urinary catheter. Review of the shower sheet (undated) revealed Resident #9's shower days were Tuesday and Thursday. Review of Resident #9's bath task dated [DATE] to [DATE] revealed no evidence the resident received a shower. Interview on [DATE] at 8:23 A.M., with Resident #9 revealed she just returned to the facility on [DATE] after being hospitalized for two months. The resident reported she has never had a shower since she was originally admitted to the facility, however she would like to have a shower. The resident reported she was dependent of staff for showering because she was a paraplegic. Interview on [DATE] at 1:35 P.M., with the Director of Nursing (DON) confirmed there was no documented evidence Resident #9 had received a shower per her preference. 2. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including hemiplegia, cerebral infarction, need assistance with personal care, dysphagia, visual lost both eyes, dermatitis, and dementia. Review of Resident #22's risk for self-care deficit: bathing, dressing, feeding plan of care initiated on [DATE] revealed to encourage the resident to participate in planning day to day care. Maintain consistent schedule with daily routine. Provide assistance with activities of daily living (ADL). Review of shower schedule (undated) revealed the resident scheduled for a shower on Tuesday, Thursday, and Friday. Review of Resident #22 bathing task dated [DATE] to [DATE] revealed the resident was bathed on [DATE] and [DATE] and was totally dependent on staff. The task did not include the type of bath (shower/bed bath) the resident received. Interview on [DATE] at 11:54 A.M., with Licensed Practical Nurse (LPN) 173 revealed Resident #22's wife has voiced concerns that staff would not provide care or check on her husband due to his inappropriate sexual behaviors. The wife has placed a camera in the room and has evidence, but she continues to have concerns. Interview on [DATE] at 1:35 P.M. with the director of nursing (DON) confirmed there was no documented evidence resident received a bath/shower on Tuesday, Thursday, or Friday except for the two documented in the electronic medical record under task on [DATE] and [DATE]. The DON confirmed the task 366241 Page 3 of 4 366241 10/02/2024 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0677 doesn't indicate what type of bath (shower or bed bath) was performed. Level of Harm - Minimal harm or potential for actual harm 3. Record review revealed Resident #43 was admitted to the facility on [DATE] and expired on [DATE]. The resident diagnoses included vertigo, cerebral infarctions, Raynaud's, history of falls, and history of transient ischemic attack. Residents Affected - Few Review of Resident #43's bathing task revealed the resident received some type of bath on [DATE], [DATE], and [DATE] and was totally dependent on staff. Interview on [DATE] at 1:35 P.M., with the DON confirmed there was no documented evidence Resident #43 received a shower on [DATE] or [DATE] per his preference. The DON confirmed the task doesn't specify what type of bath the resident received on [DATE], [DATE], [DATE]. Interview on [DATE] at 9:42 A.M., with State Tested Nurse's Aide (STNA) #171, #162, #184, #166 confirmed resident bathing preferences were not being honored. The STNA's reported they pass on to the next shift which showers were not performed on days, however they don't believe second shift were completing the showers as well because they don't even do their own scheduled showers, and dayshift tries to do second shift showers if they have time. Interview on [DATE] at 1:54 P.M., with Licensed Practical Nurse (LPN) #173 confirmed resident's bathing preferences were not being honored. The LPN reported staff report they don't have enough time to complete showers. This deficiency represents non-compliance investigated under Complaint Number OH00157827. 366241 Page 4 of 4