Health inspection·February 13, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate and consistently recorded in the record. This affected one Resident (Resident #30) of one reviewed for advanced directives. The census was 42. Findings include: Review of the medical record for Resident #30 revealed they were was admitted to the facility on [DATE]. Diagnosis included Alzheimer's Disease, hyperlipidemia, atrial fibrillation, peripheral vascular disease, dementia, anxiety disorder, major depressive disorder, and malignant melanoma of the skin. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 dated 11/26/24 revealed the resident had severely impaired cognition. They required setup or clean up assistance for eating, supervision or touching assistance for oral hygiene, substantial to maximal assistance with toileting hygiene, dressing, personal hygiene, and bed mobility. Finally, the resident was dependent on staff for showers. Review of Resident #30's medical record revealed their hard copy chart indicated the advanced directive of Do Not Resuscitate Comfort Care - Arrest (DNR-CCA), which was signed by the physician. This would indicate full medical care is given until the moment of respiratory or cardiac arrest, at which point only comfort measurers would be provided. In the Electronic Medical Record (EMR), it indicated no advanced directive in the demographic section. Interview on 02/11/25 at 12:45 P.M. with Licensed Practical Nurse (LPN) #75 revealed the first-place staff would look for the resident's code status would be in EMR and if not indicated in the EMR, they would look in the resident's hard chart located at the desk. LPN #75 confirmed Resident #30's code status was not indicated in the EMR in the demographics section where they would normally look. Interview on 02/11/25 at 12:49 P.M. with the Assistant Director of Nursing (ADON) LPN #72 revealed they confirmed staff would look for the resident's code status in the EMR and if not indicated in the EMR they would look in the resident's hard chart. Review of facility policy titled Advanced Directives Policy and Procedure, last reviewed June 2024, revealed all Advance Directive document copies will be obtained and located in the EMR and in the resident's medical record that would be readily retrievable by facility staff. Page 1 of 9 366241 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) was completed accurately upon admission to the facility. This affected one (Resident #8) of one residents reviewed for PASRR assessments. The facility census was 42. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 11/08/24 with diagnosis that included diabetes mellitus, adjust disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Review of the PASRR completed on 11/08/24 indicated Resident #8 had diagnosis of mood disorder and panic or other severe anxiety disorders. No evidence of bipolar disorder and post-traumatic stress disorder was indicated. On 02/1125 at 3:30 P.M. interview with Admissions Coordinator #59 verified Resident #8's PASRR did not include all current mental health diagnosis including bipolar disorder and post-traumatic stress disorder. 366241 Page 2 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview the facility failed to ensure resident blood pressures were monitored prior to administration of hypotensive medications and according to physician's medication order parameters. This affected one (Resident #99) of five residents reviewed for medication use. The facility census was 42. Residents Affected - Few Findings include: Review of Resident #99's medical record revealed an admission date of 01/20/25 with diagnoses that included history of falls with subdural hematoma and craniotomy, cerebrovascular accident, hypotension and hypertension. Further review of the medical record revealed a physician's order on 01/28/25 for the use of midodrine (anti-hypotensive medication) 10 milligrams (mg) three times daily with parameters to hold if systolic blood pressure is greater or equal to 150 millimeters of mercury (mmHg). Review of the Medication Administration Record (MAR) for Resident #99 revealed the medication administered as ordered with no evidence of blood pressure monitoring as indicated. On 02/12/25 at 1:40 P.M. interview with the Director of Nursing verified Resident #99's blood pressure was not monitored prior to administration of the Midodrine as ordered. 366241 Page 3 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #8's medical record revealed an admission date of 11/08/24 with diagnoses that include diabetes mellitus, adjustment disorder with mixed anxiety and depression, bipolar disorder and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 01/23/25 indicated Resident #8 had an intact and independent cognition level and required staff assistance with showers/bathing. Care Plans for Resident #8 indicated the resident required staff assistance with showers/bathing. Review of the Certified Nurse Aide (CNA) bathing records revealed only one documented shower/bath provided in the prior 30 days on 01/15/25. Interview with Resident #8 on 02/10/25 at 7:30 P.M. revealed she will miss showers at times. The resident states they receive a shower once or twice a week, but would prefer three times a week. On 02/12/25 at 1:45 P.M. interview with the Director of Nursing verified CNA staff have not been accurately documented shower/baths provided for residents including Resident #8. Review of facility policy titled Shower Policy for Country Club Manor, last reviewed February 2025, revealed the purpose was to maintain the personal hygiene and dignity of residents while ensuring that the nursing home provides a safe, clean, and respectful environment. Under the section titled Shower Sheet and Documentation, revealed 1. Completion of the Shower Sheet: After each shower (or refusal), the designated staff member will fill out a shower sheet, which will include the following, resident's name, date of shower or refusal, time of shower or refusal, reason for refusal, staff involved, outcome of attempt. 2. Shower refusal documentation: if the resident refuses, additional notes should be made in the care plan and the shower sheet. Any refusals should be reviewed regularly by the care team to assess ongoing needs or concerns. Based on interview and record review the facility failed to ensure residents medical record were complete and accurate related to documentation of care provided. This affected two residents (Resident #8 and #28) out of two residents reviewed for showers. The facility census was 42. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 07/24/23. Diagnosis included malignant neoplasm of upper lobe, left bronchus or lung, obstructive pulmonary disease, diabetes mellitus, arteriosclerotic heart disease, dependence on supplemental oxygen, pulmonary edema, hypertension, malignant neoplasm of right breast, and uterine cancer. Review of Resident #28's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had intact cognition. Resident #28 required setup and clean up assistance with eating, oral hygiene, supervision or touching assistance for toileting hygiene, personal hygiene, and bed mobility. They required partial to moderate assistance for dressing and showers. 366241 Page 4 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #28's care plan dated 10/24/24 revealed the resident required assistance with Activities of Daily Living (ADLs) related to malignant neoplasm of left bronchus or lung, intraductal carcinoma left breast, malignant neoplasm of right breast, history of shortness of breath (SOB) with exertion, SOB while lying flat, oxygen dependent, unsteady gait, and a fall prior to admission. Interventions and goals included the resident would improve current level of functions, showers every Monday, Wednesday, and Friday on night shift and as needed per the resident's preference. Review of Resident #28's Certified Nursing Assistant (CNA) tasks revealed under ADL-Bathing- Showers every Monday, Wednesday, and Fridays nights and as needed per the resident preference. Resident requests time to be around 8:00 P.M. Review of Resident #28's CNA shower task documentation revealed from 01/12/25 to 02/12/25 there was only one shower documented as completed on 02/08/25. Interview on 02/12/25 at 9:55 A.M. with the Director of Nursing (DON) confirmed there was no documentation of completed showers. Interview on 02/12/25 at 1:45 P.M. with Resident #28 revealed they received the majority of their showers. And do refuse at times if not feeling well. Interview on 02/12/25 at 2:10 P.M. with CNA #111 revealed within the last month the facility had started to document showers in the Electronic Medical Record (EMR) under the tasks tab but prior to this they were documenting on paper. CNA #111 stated, at times, they would forget to document and stated, if not documented they were not done. Interview on 02/12/25 at 2:15 P.M. with CNA #96 revealed they were to document showers in the EMR but will forget to document the showers. 366241 Page 5 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, policy review and staff interview, the facility failed to ensure an assessment for proper indication of antibiotic use was completed prior to utilizing antibiotic medications. The affected three (Residents #7, #8 and #10) of five residents reviewed for medications. The facility census was 42. Residents Affected - Few Findings include: 1. Review of Resident #7's medical record revealed an admission date of 05/09/23 with diagnosis that included Alzheimer's disease, tracheostomy and fibromyalgia. Further review of the medical record including physician's orders revealed the use of the following antibiotics:: 09/07/24, doxycycline (antibiotic)100 milligrams (mg) twice daily for nine days for a wound infection; 08/27/24, Bactrim DS (antibiotic) 800-160 mg twice daily for 10 days for cellulitis; 03/19/24, cephalexin (antibiotic) 500 mg four times daily for infection, no indication was found for use of the medication; 02/19/24, ciprofloxacin (antibiotic) 500 mg twice daily for 10 days for infectious sputum. Further review of the medical record revealed no evidence of any assessment completed to determine appropriate indication for the use of the above antibiotic medications. 2. Review of Resident #8's medical record revealed an admission date of 11/08/24 with diagnoses that included diabetes mellitus, adjust disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Further review of the medical record including physician's orders revealed the use of the following antibiotics: 12/10/24, ceftriaxone (antibiotic) one gram (gm) intramuscularly daily for seven days for a urinary tract infection.; 11/22/24, ampicillin (antibiotic) 500 mg three times daily for ten days for a urinary tract infection and 11/10/24 doxycycline 100 mg twice daily for ten days for cellulitis. Further review of the medical record revealed no evidence of any assessment completed to determine appropriate indication for the use of the above antibiotic medications. 3. Review of Resident #10's medical record revealed an admission date of 05/03/23 with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease and diabetes mellitus. Further review of the medical record including physician's orders revealed the use of the following antibiotics: 10/10/24, cephalexin (antibiotic) 250 mg every day for seven days for cellulitis; 09/06/24, cefuroxime (antibiotic) 500 mg twice daily for five days for pneumonia; 05/11/24, Augmentin (antibiotic) 875-125 mg twice daily for 10 days for pneumonia; 03/05/24, ceftriaxone (antibiotic) one gm intramuscularly for seven days for pneumonia. Further review of the medical record revealed no evidence of any assessment completed to determine appropriate indication for the use of the above antibiotic medications. On 02/12/25 at 1:10 P.M. interview with Licensed Practical Nurse (LPN) #72, revealed she was the infection preventionist for the facility and started the position in early December 2024. The pervious 366241 Page 6 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection preventionist and administrative nursing staff left no antibiotic assessments. LPN #72 verified that no antibiotic assessments were completed for Residents #7, #8 and #10 for the above dates. LPN #72 indicated the facility utilized the McGeer Criteria to determine appropriate use of antibiotics. Review of the facility policy Antibiotic Stewardship Program dated 05/2024 indicated the nurse that is receiving the orders from the physician to ensure that the infection meet the McGeer Guidelines (criteria used to determine appropriate use of antibiotics) by use of the McGeer Criteria for Infection Surveillance Checklist. Checklist should be completed with every suspected infection. 366241 Page 7 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, policy review and staff interview, the facility failed to ensure a resident was offered influenza and pneumococcal vaccines after admission to the facility. This affected one (Resident #8) of five residents reviewed for vaccines. The facility census was 42. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 11/08/24 with diagnosis that included diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Further review of the medical record including immunization revealed no evidence of any vaccines administered including influenza or pneumococcal. No evidence of any declination was found within the medical record. On 02/13/25 at 10:45 A.M. interview with Licensed Practical Nurse (LPN) #72 indicated the facility policy was to offer vaccines to residents annually and did not indicate anything related to new admission residents after the facility's annual vaccine clinic. LPN #72 verified Resident #8 was not reviewed or offered influenza or pneumococcal vaccines following admission to the facility. Review of the facility policy Influenza Vaccine dated 03/2021 indicated the influenza vaccine will be offered to all of the residents annually. The policy did not indicate any instructions for new admissions to the facility. Review of the facility policy Pneumococcal Vaccine dated 03/2021 revealed no instructions for new admissions to the facility including review and offering vaccines. 366241 Page 8 of 9 366241 02/13/2025 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on medical record review, policy review and staff interview, the facility failed to ensure a resident was offered COVID-19 vaccines after admission to the facility. This affected one (Resident #8) of five residents reviewed for vaccines. The facility census was 42. Findings include: Review of Resident #8's medical record revealed an admission date of 11/08/24 with diagnosis that included diabetes mellitus, adjust disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Further review of the medical record including immunization revealed no evidence of any vaccines administered including COVID-19. No evidence of any declination was found within the medical record. Review of the undated facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents and Staff revealed no evidence of instructions regarding offering and/or reviewing of vaccines following admission to the facility. On 02/13/25 at 10:45 A.M. interview with Licensed Practical Nurse (LPN) #72 indicated the facility policy was to offer vaccines to residents annually and did not indicate anything related to new admission residents after the facility annual vaccine clinic. LPN #72 verified Resident #8 was not reviewed or offered COVID-19 vaccine following admission to the facility. 366241 Page 9 of 9