Health inspection·February 9, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 interviews, the facility failed to ensure resident assessments were accurately completed. This affected two (Residents #6 and #48) of four residents reviewed for Minimum Data Set (MDS) 3.0 assessments recorded for pain. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 09/06/22 with diagnoses including diabetes mellitus and pain in the right shoulder. Review of the pain assessment dated [DATE] revealed Resident #6 had pain in the previous five days to her lower extremities rating it as a six on a scale of zero to ten. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #6 had intact cognition. Review of section J revealed the question, should staff attempt to conduct an interview with the resident, was marked yes. However, the pain assessment interview was answered not assessed. The assessment was signed by Licensed Practical Nurse (LPN) #821, dated 12/10/22. Interview on 02/07/23 at 10:40 A.M. with LPN #821 verified the pain assessment on the quarterly MDS 3.0 assessment was not completed and she had answered not assessed as she believed it had to be done on the Assessment Reference Date (ARD) as it had a look-back period of five days. LPN #821 stated she used the information from the pain assessments that the nursing staff completed in the medical record. Interview on 02/07/23 at 11:38 A.M. with the Director of Nursing (DON) revealed pain assessments are done weekly but don't always coincide with the resident's MDS assessment as she does not know when the MDS assessments are scheduled. Interview on 02/07/23 at 2:13 P.M. with LPN #821 verified the RAI manual stated the look-back period on section J of the MDS 3.0 assessment is five days and the assessment should be conducted close to the end of the five day look-back period, preferably on the day before or the day of the ARD. She verified there was a pain assessment dated [DATE] and the MDS was dated 12/07/22. 2. Review of the medical record for Resident #48 revealed an admission date of 09/27/22 with diagnoses including hypertension, dementia, difficulty in walking, anxiety and depression. Review of the pain assessment dated [DATE] revealed Resident #48 had pain over the previous five days to her bilateral lower extremities rating it as happening occasionally and at a seven on a scale Page 1 of 5 366260 366260 02/09/2023 Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683

F 0641 of zero to ten. Level of Harm - Minimal harm or potential for actual harm Review of the modified quarterly MDS 3.0 assessment dated [DATE] revealed Resident #48 had impaired cognition. Review of section J revealed the question, should staff attempt to conduct an interview with the resident, was marked yes. However, the pain assessment interview was answered not assessed. The assessment was signed by Licensed Practical Nurse (LPN) #821, dated 10/06/22. Residents Affected - Few Interview on 02/07/23 at 10:40 A.M. with LPN #821 verified the pain assessment on the quarterly MDS 3.0 assessment was not completed and she had answered not assessed as she believed it had to be done on the ARD as it had a look-back period of five days. LPN #821 stated she used the information from the pain assessments that the nursing staff completed in the medical record. Interview on 02/07/23 at 11:38 A.M. with the DON revealed pain assessments are done weekly but don't always coincide with the resident's MDS assessment as she does not know when the MDS assessments are scheduled. Interview on 02/07/23 at 2:13 P.M. with LPN #821 verified the RAI manual stated the look-back period on section J of the MDS 3.0 assessment is five days and the assessment should be conducted close to the end of the five-day look-back period, preferably on the day before or the day of the ARD. She verified there was a pain assessment dated [DATE] and the MDS was dated 10/05/22. 366260 Page 2 of 5 366260 02/09/2023 Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to obtain a physician order for oxygen administrations and to document weekly oxygen tubing changes for Resident #24. This affected one resident (Resident #24) of two residents reviewed for oxygen administration. The facility census was 48. Residents Affected - Few Findings include: Review of medical records for Resident #24 revealed an admission date of 08/21/20 and diagnosis of malignant neoplasm (cancer) of the bronchus or lung, chronic obstructive pulmonary disease (COPD), and acute bronchitis. Review of the physician's orders for February 2023 revealed Resident #24 did not have an order for oxygen administration or for nursing staff to change her nasal cannula and oxygen tubing once a week. Nursing progress dated 02/01/23 at 09:14 P.M. written by Registered Nurse (RN) #845 revealed resident's respirations were easy and non-labored on oxygen at two liters via nasal cannula. Observation and interview on 02/06/23 at 11:33 A.M. with Resident #24 revealed she was on oxygen via nasal cannula all the time except when going out to smoke. The nasal cannula was not dated to indicate when the tubing was last changed. Resident #24 stated they change her tubing on Sundays. Interview on 02/08/23 at 08:37 A.M. with Licensed Practical Nurse (LPN) #829 verified Resident #24 has no order for oxygen or to have her nasal cannula and oxygen tubing changed weekly. Review of the facility policy titled, Respiratory: Oxygen Administration via Nasal Cannula, revision on 08/25/12, revealed staff were to verify the physician's order, label the nasal cannula with date and to document the date, time, and service rendered in the medical record. 366260 Page 3 of 5 366260 02/09/2023 Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy review, the facility failed to ensure food was properly covered and dated, and failed to ensure staff delivered residents' trays in a sanitary manner. This had the potential to affect 42 of 42 residents on a regular diet, and four (Residents #1, #6, #10 and #34) of 20 residents residing on the 300 hall that were observed during the lunch meal service. Findings include: 1. Observation of the kitchen on 02/06/23 at 8:15 A.M. with the Dietary Manager (DM) revealed, in the refrigerator, 19 cups of fruit cocktail and 19 cups of gelatin with fruit, all uncovered, undated, and open to air. Interview on 02/06/23 at 8:20 A.M., the DM confirmed the food was not properly covered and dated. Review of the facility policy, Food Storage-Labeling and Dating, dated July 2018, revealed all foods should be securely closed to avoid being exposed to the air. 2. During observation of the lunch tray delivery on 02/06/23 at 12:43 P.M., Registered Nurse (RN) #32 did not perform hand hygiene before or after providing tray delivery and set-up assistance to two (Resident #1 and Resident #34). Interview on 02/06/23 at 12:48 P.M., RN # 32 confirmed that she did not perform any hand hygiene during the delivery of the lunch trays. Review of policy titled, Foundations Health Solutions Infection Control Policy/Procedure Manual, dated 08/18/10, revealed all staff shall perform hand hygiene before and after performing resident care procedures and per our facility's established hand hygiene procedure.3. Observation on 02/06/23 at 12:37 P.M. of the lunch meal service revealed State Tested Nurse Aide (STNA) #835 to go to Resident #6's room with her lunch tray, place it on the tray table, open the food containers for the resident and then walk back to the tray cart. STNA #835 then took Resident #10's tray out of the tray cart, go into Resident #10's room, place it on her tray table, open the food containers for the resident and then walk back to the tray cart. She was not observed to use hand hygiene in between residents. Interview on 02/06/23 at 12:44 P.M. of STNA #835 verified she did not perform hand hygiene in between delivering trays to Residents #6 and #10. 366260 Page 4 of 5 366260 02/09/2023 Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to implement proper infection control policies and procedures to ensure staff followed contact isolation precautions (wearing gown and gloves) and having trash and linen barrels available for Resident #19. This affected one (Resident #19) of two resident reviewed for contact isolation. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed he was admitted on [DATE] with diagnoses including hypertension and dementia. He was diagnosed on [DATE] with Clostridium Difficile (a contagious bacteria that causes diarrhea and inflammation of the colon). Review of the physician's orders dated 02/01/23 revealed Resident #19 was on contact precautions for Clostridium Difficile until 02/15/23. Observation on 02/06/23 at 11:25 A.M. of Resident #19 with State Tested Nurse Aide (STNA) #835 revealed he was on contact precautions. The sign stated everyone must clean their hands before entering and leaving the room, put on gloves before room entry and discard gloves before room exit, and to put on a gown before room entry and discard gown before room exit. An isolation cart was observed outside of Resident #19's room with adequate personal protective equipment (PPE). There was no laundry hamper with a biohazard liner nor a waste container with a red liner noted in his room or bathroom. STNA #835 verified a laundry hamper or waste container was not available in the room and that they should be present in the room. She stated staff had been disposing of Resident #19's incontinence brief, trash and PPE in the trash. Observation on 02/08/23 at 7:38 A.M. revealed Licensed Practical Nurse (LPN) #829 went into Resident #19's room to administer medications. LPN #829 was observed to go to Resident #19's bed, bend down on her knees where they touched the bed and her feet were on his fall mat. She then utilized the bed remote to place him in a sitting position. She was observed to touch the resident and his bedding while giving him his medications. Resident #19 was noted to refuse medications and fluids. LPN #829 then sat on the side of his bed while she was encouraging him to take his medications. During the observation, LPN #810, who is also the Assistant Director of Nursing (ADON) was in the hall and verified Resident #19 was still on contact precautions for Clostridium Difficile. She stated LPN #829 should have been wearing a gown and gloves. LPN #829 was observed wearing a surgical mask and face shield. LPN #829 verified she had forgot to put gown and gloves on before caring for Resident #19. Review of the facility policy titled, Infection Control-Isolation, Initiating, revised July 2006, revealed when isolation precautions are implemented, the unit manager, infection control coordinator or designee shall be sure a laundry hamper with melt-away bag or biohazard liner and waste containers with a red liner are placed in the isolation room. Review of the facility policy titled, Clostridium Difficile, revised May 2017, revealed staff are to wear appropriate personal protective equipment to prevent exposure to spills or splashes of potentially infectious materials and to maintain contact precautions as indicated. 366260 Page 5 of 5