Health inspection·September 25, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of liability notices, and staff interview, the facility failed to ensure a resident received appropriate notice prior to the end of their Medicare (MCR) Part A services and residents that opted to receive those services continued to receive them while MCR was billed for an official decision on payment. This affected two residents (#1 and #48) of three residents reviewed for liability notices. Residents Affected - Few Findings include: 1. A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE]. Her diagnoses included end stage renal disease, dependence on renal dialysis, dementia with a mood disturbance, congestive heart failure and chronic obstructive pulmonary disease. Her diagnoses list was updated n 05/01/23 to reflect she had a below the knee amputation of the right leg. A review of Resident #1's Notice of MCR Non-Coverage (NOMNC) revealed her skilled services ended on 05/24/23. The resident received the notice on 05/22/23 providing her with at least a 48 hour notice as required. In addition to the NOMNC, the resident received a skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) that informed her beginning on 05/24/23 she may have to start paying out of pocket for her care, if she did not have any other insurance that may cover those costs. The care specified was occupational therapy, physical therapy, speech therapy, and nursing care. The reason MCR was indicated that they may not pay was due to the resident meeting her maximum potential. The estimated cost of those services was $200.00. The resident chose option 1 on the SNFABN indicating she wanted to continue to receive the care above and wanted MCR to be billed for an official decision on payment. She acknowledged that if MCR did not pay, she would be responsible for paying for those services, but could appeal to MCR by following the directions on the Medicare Summary Notice (MSN). Resident #1's medical record was absent for any evidence of her to continue to receive the care that she elected to continue to receive pending a MCR decision on payment. Findings were verified by Registered Nurse (RN) #488. On 09/21/23 at 9:16 A.M., an interview with RN #488 revealed she could not find any evidence of Resident #1 continuing to receive her skilled service, after 05/24/23, as elected by the resident pending a MCR decision. She suspected the form may have been marked incorrectly by the staff member completing it. 2. A review of Resident #48's medical record revealed she was originally admitted to the facility Page 1 of 17 366285 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on [DATE] and most recently readmitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation and atrial fibrillation. Her diagnoses list was updated on 04/20/23 to include the diagnoses of an atrioventricular block- second degree, syncope and collapse, and placement of a cardiac pacemaker. A review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. Her cognition was assessed as being severely impaired. A review of Resident #48's NOMNC revealed her last covered day for MCR Part A services was on 07/13/23. The resident was informed of her last covered day of MCR Part A services on 07/13/23 (day of her last covered day) and was not provided a 48 hour notice as required. The resident signed the NOMNC acknowledging her skilled service would end on 07/13/23, despite her cognition being severely impaired. The notice was not signed by her resident representative (daughter). A review of Resident #48's SNFABN revealed the facility provided a SNFABN for an end of service beginning on 05/11/23. They did not provide a SNFABN for her end of service on 07/13/23. There was no evidence provided of a SNFABN being provided to the resident when her skilled service ended on 07/13/23. On 09/16/23 at 9:16 A.M., an interview with RN #488 confirmed Resident #48 was not given timely notice of her MCR Part A services ending on 07/13/23. She acknowledged the resident/ resident representative should have received at least a 48 hour notice before her skilled service ended. The facility denied they had a policy specific to liability notices. They contacted the regional office who told them they just followed Centers for Medicare and Medicaid Services (CMS) regulations. 366285 Page 2 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, interview, and facility policy review, the facility failed to ensure residents who were being transferred to the local emergency room for care received a copy of the bed hold notice. This affected two residents (#24 and #66) of two residents reviewed for hospitalization. The facility census was 69. Findings included: 1. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, stage three, acute and chronic combined systolic and diastolic heart failure, neuromuscular dysfunction of the bladder, weakness, and essential hypertension. Review of Resident #24's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/25/23, revealed she was cognitively intact and had active diseases of chronic kidney disease, stage three and heart failure. Review of Resident #24's progress note dated, 08/01/23 at 1:30 P.M., revealed her daughter was called and updated on her mother being sent to the emergency room for evaluation of increasing edema to her legs and blistering skin to left lower limb with an open wound to her left medial lower leg draining a large amount of clear fluid. Review of Resident #24's medical record revealed no documentation to support the facility provided the resident and/or the resident's representative information regarding the facility policy for bed hold on 08/01/23. Interview on 09/20/23 at 10:47 A.M. with Business Office Manager (BOM) #447 verified there was no bed hold notice for Resident #24 due to her stay being covered by insurance. BOM #447 revealed she was not aware that residents with pay sources other than Medicaid were to be offered a bed hold notice. 2. Review of Resident #66's medical record revealed she was admitted to the facility on [DATE] with diagnoses including encephalopathy, malignant melanoma of skin, urinary tract infection, and morbid obesity. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/21/23, revealed she was cognitively intact and had a multidrug resistant organism (MDRO). Review of Resident #66's progress note, dated 07/05/23, revealed she was transferred from the facility on 07/05/23 via emergency medical services to a local emergency room. Review of Resident #66's medical record revealed no documentation to support the facility provided the resident and/or the resident's representative information regarding the facility policy for bed hold on 07/05/23. Interview on 09/20/23 at 10:47 A.M. with BOM #447 verified there was no bed hold notice for 366285 Page 3 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #66 due to her being skilled care. BOM #447 revealed she was not aware that residents with pay sources other than Medicaid were to be offered a bed hold notice. Review of the facility policy titled, Notice of Bed Hold Policy, dated 02/18, revealed the document must be signed by the patient upon discharge to the hospital or therapeutic leave. Further review revealed the top section was to be completed upon admission and the bottom section was to be completed if the resident leaves the center for a hospitalization or therapeutic leave to reflect the resident's decision to hold or not hold the resident's bed, subsequent to any State required bed hold period. 366285 Page 4 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three residents (#44, Resident #9, and Resident #15) of three residents reviewed for PASARR documents. The census was 69. Findings Include: 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, osteomyelitis, major depressive disorder, bipolar disorder, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively intact, and had diagnoses of dementia, depression and bipolar disorder. Review of Resident #44's PASARR document, dated 10/27/22, revealed under Section E, there were no diagnoses listed. Review of the resident's diagnoses list revealed bipolar disorder and major depressive disorder were added on 01/24/20. During interview on 09/20/23 at 8:37 A.M., Regional Registered Nurse (RN) #488 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of depression and bipolar disorder. 2. Review of Resident #9's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (entered 09/26/23), anxiety disorder (entered 09/26/18), other psychotic disorder not due to a substance of known physiological condition (entered 05/29/15), and dysthymic disorder (entered 05/29/15). Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/26/23, revealed she was rarely/never understood, and had short-term and long-term memory problems. Further review revealed she had active diagnoses of anxiety disorder, depression, and psychotic disorder. Review of Resident #9's most recent PASARR, dated 12/13/07, revealed under Section D: Indications of Serious Mental Illness, the boxes beside mood disorder, panic or other severe anxiety disorder, and personality disorder were marked with an X. Interview on 09/19/23 at 7:48 A.M. with Social Services Designee #452 verified Resident #9's most recent PASARR was not accurate and up to date. She verified the PASARR had documented Resident #9 had a personality disorder when none was noted in her medical record and the PASARR did not have documented a psychotic disorder, which was an active diagnosis. She verified Resident #9 could be eligible for mental health services if the PASARR was completed accurately. 3. Review of Resident #15's medical record revealed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, current episode depressed (entered 07/18/23), major depressive disorder, recurrent, moderate (entered 08/11/22), generalized anxiety disorder (entered 08/11/22), and post-traumatic stress disorder (PTSD) (entered 08/11/22). 366285 Page 5 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #15's annual Minimum Data Set (MDS) 3.0 assessment, dated 07/21/23, revealed she was cognitively intact. Further review revealed her active diagnoses included anxiety disorder, depression, and PTSD. Review of Resident #15's psychiatric progress note, dated 05/16/23, revealed mental health diagnoses of bipolar, panic disorder, general anxiety disorder and PTSD. There was no diagnosis of psychosis. Review of Resident #15's psychiatric progress note, dated 08/08/23, revealed mental health diagnoses of bipolar, panic disorder, general anxiety disorder and PTSD. There was no diagnosis of psychosis. Review of Resident #15's most recent PASARR, dated 07/28/23, revealed under Section E: Indications of Serious Mental Illness, the boxes beside mood disorder, panic or other severe anxiety disorder and other psychotic disorder marked with an X. Interview on 09/19/23 at 7:55 A.M. with Social Services Designee #452 verified Resident #15's most recent PASARR was not accurate and up to date. She verified the PASARR revealed a psychosis disorder and there was none documented in the diagnoses. She verified Resident #15 could be eligible for mental health services if the PASARR was completed accurately. Interview on 09/19/23 at 8:17 A.M. with Regional Registered Nurse (RN) #488 revealed she coded Resident #15's PASARR with a psychosis diagnosis due to her diagnosis of PTSD. She presented this surveyor with a website which revealed PTSD was a psychiatric condition. RN #488 verified that PTSD was a psychiatric condition but fell under an anxiety disorder and not a psychosis disorder. 366285 Page 6 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

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 record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with the removal of unwanted facial hair. This affected one resident (#48) of three residents reviewed for activities of daily living (ADL's). Residents Affected - Few Findings include: A review of Resident #48's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, dementia with agitation, depression, anxiety disorder, difficulty walking, weakness, and abnormalities of gait and mobility. A review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She was not known to have rejected any care during the seven days of the assessment period. She required an extensive assist of one for transfers and personal hygiene and was totally dependent on one for bathing. A review of Resident #48's care plans revealed she had a care plan in place for being at risk for a decline in ADL function related to an alteration in ADL performance/participation related to impaired mobility, impaired balance, decreased range of motion to her right elbow, and dementia. Her goal was for the resident's needs to be met with regard to ADL's. Her interventions included encouraging her participation while performing ADL's, staff to anticipate her needs and assist as needed, and to try to make her ADL routine consistent to foster recognition of necessary tasks. A review of Resident #48's bathing activity documented under the task tab of the electronic health record revealed she had been receiving bed baths as her bathing activity. The last bed bath was documented as having been received on 09/19/23. She required an extensive assist with the physical assist of one for personal hygiene which included shaving. On 09/18/23 at 1:54 P.M., an observation of Resident #48 noted her to have a few long, white hairs on her chin. Follow up observations on 09/19/23 at 10:18 A.M. revealed the resident continued to have a few long, white hairs on her chin that had not been removed. On 09/19/23 at 1:05 P.M., an interview with State Tested Nursing Assistant (STNA) #404 revealed Resident #48 required an extensive assist of one for personal hygiene. She was asked what the facility staff did for female residents who was noted to have facial hair. She stated they would use a straight razor to shave it. She reported the resident was compliant with the removal of unwanted facial hair when that was needed. She was asked to check Resident #48 to see if she had any facial hair that needed to be removed. She confirmed the resident had several long white hairs on her chin and they had been growing a little while to get to the length they were. She asked the resident if she wanted her to shave the long hairs she had on her chin. The resident replied that would be fine with her. 366285 Page 7 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure Resident #32's constipation was treated timely. This affected one resident (#32) of two residents reviewed for constipation. Residents Affected - Few Findings include: Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including fracture of the cervical vertebra, fracture of the right femur, dementia, and interstitial pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/08/23, indicated the resident was severely cognitively impaired. The MDS assessment revealed the resident required extensive, two-person assistance with bed mobility, transfers, and toileting. Review of the Care Plan, dated 03/13/23, revealed the resident was at risk for pain with interventions including to monitor/document for side effects of pain medications and to observe for constipation and to report occurrences to the physician. Review of a physician order, dated 03/01/23, revealed the order for Docusate Sodium 100 milligrams (mg), to give one capsule every 12 hours as needed for constipation. Review of Resident #32's Medication Administration Record (MAR), dated August 2023, revealed Docusate Sodium 100 mg as needed for constipation was not administered during the month. Review of Resident #32's Bowel Control/Frequency Log, revealed there was no bowel movement on 08/26/23, 08/27/23, 08/28/23, 08/29/23, 08/30/23, or 08/31/23. Review of the nursing progress notes revealed no evidence of intervention or physician notification. The resident did have a bowel movement on 09/01/23. During interview on 09/19/23 at 2:38 P.M., Regional Registered Nurse (RN) #448 confirmed Resident #32 did not have a bowel movement between 08/26/23 through 08/31/23 and Docusate Sodium 100 mg was not administered for constipation as ordered by the physician. Review of the facility's policy titled, Bowel Habit Guidelines, dated 2018, revealed normal bowel habit is clinically defined as at least every three to five days and can be different for each individual person. After appropriate nursing interventions are found to be unsuccessful and as needed medications are unsuccessful, the charge nurse will notify the physician for further orders. 366285 Page 8 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

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 record review, observation, interview, and policy review, the facility failed to properly store Resident #19's nebulizer machine, tubing, and mouthpiece and failed to ensure Resident #31 received the correct dosage of oxygen as ordered by the physician. This affected two residents (#19 and #31) of two residents reviewed for respiratory care. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including myocardial infarction, dementia, obesity, and weakness. Review of Resident #19's physician orders, dated 02/27/23, revealed the order for ipratropium-albuterol solution 0.5-2.5 milligrams (mg)/2 milliliters (ml), inhale orally every four hours as needed for shortness of breath via nebulizer. Review of the Medication Administration Record (MAR) dated September 2023, revealed the resident was administered the nebulizer treatment on 09/16/23. Observation on 09/18/23 at 12:26 P.M., revealed Resident #19 lying in bed with her eyes closed. Resident #19's nebulizer machine, tubing, and mouthpiece were lying on the floor, near the side of the resident's bed. A subsequent observation on 09/18/23 at 12:25 P.M. revealed Resident #19 was not in her room. The nebulizer machine, tubing, and mouthpiece were still lying on the floor in the same area as previously observed. During interview and observation on 09/18/23 at 12:26 P.M., Licensed Practical Nurse (LPN) #444 removed the nebulizer machine, tubing, and mouthpiece from the floor and confirmed that it should not be on the floor and should have been stored properly. During interview on 09/19/23 at 2:26 P.M., Regional Registered Nurse (RN) #448 confirmed the nebulizer machine, tubing, and mouthpiece should not have been on the floor. Review of the facility's policy titled, Oxygen Handling, January 2021, revealed it is the policy to administer and handle oxygen in a safe and responsible manner at all times. 2. Review of Resident #31's medical record revealed he was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including fracture unspecified of the neck of the left femur, anxiety disorder, retention of urine, unspecified, neuromuscular dysfunction of the bladder, and acute respiratory failure with hypoxia. Review of Resident #31's significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/25/23, revealed he was cognitively intact. Further review revealed he received oxygen while a resident. Review of Resident #31's plan of care, dated 07/26/23, revealed he had oxygen therapy related to ineffective gas exchange. An intervention included oxygen settings: oxygen via nasal cannula per orders, humidified. Review of Resident #31's physician order, dated 07/09/23, identified he was to have oxygen at 3 to 366285 Page 9 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0695 Level of Harm - Minimal harm or potential for actual harm 5 liters(L)/minute (min) per nasal cannula to maintain an oxygen saturation above 92%. He was to have oxygen every day and night shift. Review of Resident #31's medication administration record (MAR), dated September 2023, revealed he was receiving his oxygen at 3 L/min. Residents Affected - Few Observation on 09/18/23 at 10:05 A.M. revealed Resident #31 lying in bed with a nasal cannula in his nose. Observation of his oxygen concentrator revealed his oxygen was running at 2 L/min. Observation on 09/19/23 at 7:11 A.M. revealed Resident #31 lying in bed, his nasal cannula in his nose, and his oxygen being administered at 2.5 L/min per his oxygen concentrator. Observation on 09/19/23 at 10:17 A.M. revealed Resident #31 lying in bed, his nasal cannula in his nose, and his oxygen being administered at just above 2 L/min per his oxygen concentrator. At the time of the observation, Assistant Director of Nursing (ADON) #433 verified Resident #31's oxygen was running at 2 L/min or just above 2 L/min. ADON #433 reviewed Resident #31's medical orders and verified his oxygen was not running at the correct dosage. Review of the facility policy titled, Oxygen Handling, undated, revealed a physician's order is required for routine and PRN (as needed) use of oxygen. 366285 Page 10 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the dialysis contract, and staff interview, the facility failed to ensure dialysis communication forms were completed by the facility and the dialysis center to maintain good communication of the resident's condition and services rendered during dialysis treatments. This affected one resident (#1) of one resident reviewed for hemodialysis treatments. Residents Affected - Few Findings include: A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (ESRD) and dependence on renal dialysis. A review of Resident #1's physician's orders revealed she received dialysis treatments every Tuesday, Thursday, and Saturday. That order had been in place since 05/09/23. A review of Resident #1's care plans revealed she had a care plan in place for receiving dialysis every Tuesday, Thursday, and Saturday related to ESRD. The interventions included checking for new orders upon the resident's return from dialysis and maintaining communication with dialysis staff and physician. A review of the weekly hemodialysis communication sheets revealed the facility staff and the dialysis center's staff were not consistently completing their sections of the weekly hemodialysis communication sheets when the resident was sent out for her dialysis treatments. The facility's nurses were to document any concerns or problems that have occurred with the resident since her last dialysis treatment. They were also to communicate any new medications or changes in medications since her last treatment. The dialysis center's staff was to complete pre and post-dialysis weights and vital signs, medications given, complications if occurred, and any new orders given that the facility staff should be made aware of. The weekly dialysis communication sheets were maintained in a binder that was sent with the resident for each dialysis treatment. A review of the weekly hemodialysis communication sheets from 07/19/23 through 09/19/23 revealed the facility's nurses failed to complete their required documentation eight times during that two month period. Missing pre-dialysis documentation was noted for 07/18/23, 07/20/23, 07/22/23, 08/05/23, 08/08/23, 08/10/23, 08/22/23 and 08/24/23. The dialysis center's staff failed to provide any documentation of the resident's pre and post dialysis weights and vital signs, medications given, complications, and new orders five times during that same two month period. Missing documentation was noted for 07/29/23, 08/03/23, 08/26/23, 08/29/23, and 09/14/23. On 09/20/23 at 10:20 A.M., an interview with Licensed Practical Nurse (LPN) #484 revealed communication between the facility and the dialysis center was maintained by completing the weekly hemodialysis communication sheets. He confirmed the facility's nurse was supposed to complete the top section of the form and the dialysis center's staff was supposed to fill out the bottom half for each dialysis treatment the resident went out for. The facility's nurse was supposed to review the communication form to make sure there were no changes in the resident's condition or for new orders that may have been received as a result of that dialysis visit. On 09/20/23 at 10:30 A.M., findings were confirmed with Registered Nurse (RN) #488 that Resident #1's dialysis communication sheets were not consistently being completed by the facility's nurses or 366285 Page 11 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dialysis center's staff with each dialysis treatment the resident received. She confirmed documentation should be completed by both when the resident was sent out for her dialysis treatments. A review of the facility's dialysis contract with the dialysis provider revealed the facility should ensure that all appropriate medical information accompany the resident at the time of transfer to the dialysis center. That information should include any information that would facilitate the adequate coordination of care, as reasonably determined by the dialysis center. 366285 Page 12 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses including chronic respiratory failure, morbid obesity, type two diabetes, and chronic obstructive pulmonary disease. Residents Affected - Few Review of Resident #15's annual MDS 3.0 assessment revealed she was cognitively intact and always incontinent of bowel and bladder. Review of Resident #15's physician order, dated 09/20/23, identified she was to receive Senna-Plus tablet (a laxative) 8.6-50 milligram (mg) one tablet by mouth every 12 hours as needed for constipation. Further review revealed she was to receive Loperamide HCL (an antidiarrheal agent) 2 mg by mouth every 4 hours as needed for diarrhea. Review or Resident #15's State Tested Nursing Assistants' (STNA) documentation in tasks for the past 30 days revealed her bowel consistency on the following dates were loose/diarrhea: 08/24/23, 08/26/23, 08/27/23, 08/29/23, 08/30/23, 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/06/23, 09/10/23, 09/12/23, 09/13/23, 09/14/23, 09/16/23, 09/17/23, 09/18/23, and 09/19/23. Review of Resident #15's medication administration record (MAR) dated for August 2023, revealed she received Senna-Plus tablet 8.6-50 mg one tablet by mouth two times a day for constipation for all 31 days the month of August. Review of Resident #15's MAR, dated September 2023, revealed she received Senna-Plus tablet 8.6-50 mg one tablet by mouth two times a day for constipation from 09/01/23 to 09/19/23. Further review revealed she received Loperamide HCL tablet 2 mg by mouth on 09/17/23 for diarrhea. Interview on 09/21/23 at 9:00 A.M. with Licensed Practical Nurse (LPN) #492 verified Resident #15 had mostly loose/diarrhea stools for the past 30 days. She also verified that the Senna-Plus tablet should not have been given if the resident was having loose stools and it was contradictory to give the Senna-Plus tablet and Loperamide on the same day. LPN #492 revealed she had never been informed by the STNAs that Resident #15 had loose/diarrhea stools. Based on medical record review and interview the facility failed to ensure residents were free from unnecessary medications. This affected two residents (#11 and #15) of seven residents reviewed for unnecessary medication. The facility census was 69. Findings include: 1. Record review revealed Resident #11 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, sepsis due to Escherichia coli, extended spectrum beta lactamase (ESBL) resistance, diffuse large b-cell lymphoma, intra-abdominal lymph nodes, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia with lower urinary tract symptoms, sleep apnea, insomnia, and overactive bladder. Review of the Minimum Data Set (MDS) assessment from 08/21/23 also revealed Resident #11 had a Stage 3 pressure ulcer to the coccyx present on admission and experienced frequent bowel incontinence. Review of Resident #11's medical record revealed an order dated 09/03/23 for senna-plus 8.6-50 milligrams (mg) tablets (Sennosides-Docusate Sodium) with directions to give two tablets by mouth two 366285 Page 13 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0757 times a day for constipation, with directions to hold when the resident has loose stools. Level of Harm - Minimal harm or potential for actual harm Further review of the medical record revealed Resident #11 had loose stools or diarrhea documented at 3:23 P.M. and 11:00 P.M. on 09/04/23, at 2:50 P.M. on 09/05/23, at 12:20 A.M. and 4:09 A.M. on 09/15/23, and at 4:20 P.M. on 09/16/23. The medication administration record for the month of September 2023 revealed senna-plus was given twice per day and was not held as directed per the physician order. Residents Affected - Few Interview on 09/18/23 at 1:22 P.M. with Resident #11 revealed a history of bowel blockage when he was admitted to the facility which turned into frequent bowel movements, then regular bowel movements, and back to diarrhea. Resident #11 stated he has had diarrhea again for a couple days and he had an incontinent episode of a large diarrhea through the night after passing gas. Interview on 09/20/23 at 8:30 AM with Resident #11 revealed he was feeling ill this morning and started with diarrhea through the night. Resident #11 stated yesterday was the only day this week without diarrhea. He verbalized he was so tired of having diarrhea and was frustrated it returned. He was uncertain if the facility was doing anything to address his diarrhea. Interview on 09/20/23 at 10:22 A.M. with Regional Registered Nurse (RN) #490 confirmed the medical record indicated Resident #11 had a loose bowel movement on 09/15/23 at 12:20 A.M. and 4:09 A.M. and again on 09/16/23 at 4:20 P.M. Regional RN #490 further confirmed Resident #11 received Senna-Plus 8.6-50mg, 2 tablets in the morning and at bedtime on both 09/15/23 and 09/16/23. Interview on 09/21/23 at 8:48 AM with Regional RN #488 confirmed Senna-Plus was not held on 09/04/23 or 09/05/23 for loose stools. Regional RN #488 stated the facility would not hold the senna-plus for just one episode of diarrhea. Regional RN #488 then acknowledged there were three consecutive diarrheic episodes documented between 09/04/23 and 09/05/23 and added that the medication was not held per nursing judgement, citing no pattern of loose bowels. Regional RN #488 confirmed there is no written policy or procedure indicating how many loose bowel movements should be documented before holding medication for loose stools. 366285 Page 14 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

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 observation, interview, facility document review and facility policy review the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when caring for COVID-19 positive residents, performed hand hygiene and disposed of sharps appropriately, and failed to ensure the disinfectant wipes outside of COVID-19 isolation rooms was not expired. Staff not wearing the appropriate PPE and the expired disinfectant wipes had the potential to affect all 56 residents residing in the facility who had not tested positive for COVID-19. The hand hygiene concern affected Resident #233 and the improper disposal of sharps had the potential to affect all residents residing in the facility. The facility census was 69. Residents Affected - Many Findings included: 1. Observation on [DATE] at 9:00 A.M. upon entrance into the facility revealed signage on the entrance door reading Please be aware that (Facility Name) is currently in Outbreak due to Positive staff/residents which informed those who enter the building that the facility was in an active state of COVID-19 outbreak. Review of the facility order listing report, dated [DATE], revealed there were 13 Residents (#2, #8, #11, #12, #15, #22, #29, #62, #66, #72, #74, #223, #236) in the facility which were positive for the COVID-19. Observation on [DATE] at 8:54 A.M. of State Tested Nurse Aide (STNA) #491 standing in the open doorway of Resident #8 and #74's shared room who were on COVID isolation due to testing positive for the COVID-19 virus. She had an isolation gown on and a surgical mask. She had her regular eyeglasses on but no goggles or a face shield and she was not wearing gloves. She received a tray from STNA #427. Interview on [DATE] at 8:56 A.M. with STNA #491, after she exited Resident #8 and #74's room, verified while in the room she was wearing an isolation gown and surgical mask as her PPE. She verified she was not wearing a N-95 mask and should have been, she verified she was wearing her vision glasses but no appropriate eye protection (face shield or protective goggles) and should have been , and she verified she was not wearing any gloves and should have been. She reported she usually worked in the memory care unit, and she was not used to wearing PPE when caring for residents who had tested positive for COVID-19. This surveyor did not observe STNA #491 enter any other resident rooms after exiting Resident #8 and #74's room. STNA #427 donned (put on) the appropriate PPE to enter the next isolation room. Interview on [DATE] at 9:30 A.M. with Regional RN #490 verified STNA #491 had been sent home from work due to her potential exposure to COVID-19 secondary to not wearing the appropriate PPE while in the room with residents who had tested positive for COVID-19 . Interview on [DATE] at 12:27 P.M. with STNA #427 verified she was handing breakfast trays to STNA #491. STNA #427 verified since STNA #491 was not wearing the appropriate PPE to care for residents who had tested positive for COVID-19, she donned the appropriate PPE and went into the next isolation room and had STNA #491 stay in the hallway and hand her trays. She reported STNA #491 was then sent home. Review of the facility policy titled Infection Control Prevention Program, revised 11/22, revealed 366285 Page 15 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Residents have the right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. Further review revealed the goals of the facility infection prevention program are to reduce the spread of infectious disease within the facility, decrease the risk of infections within the facility through standard and transmission-based precautions, and monitor for occurrence of infection and implement appropriate control measures. Review of the Post Public Health Emergency (PHE) Guidance, dated 05/23, revealed when entering a transmission-based isolation room appropriate PPE is required (mask, protective eyewear, gloves, gown). 2. Observation on [DATE] at 1:45 P.M. of Licensed Practical Nurse (LPN) #492 administering an intravenous antibiotic to Resident #233. She donned (put on) the appropriate PPE due to the resident being on COVID-19 isolation. LPN #492 entered the room and disconnected and discarded the intravenous antibiotic bag which had been administered earlier in the day from the intravenous tubing. LPN #492 then doffed (removed) her gloves and donned new gloves. She did not perform any hand hygiene between doffing of the old and donning of the new gloves. LPN #492 then proceeded to connect the intravenous tubing to the antibiotic bag being administered. Interview on [DATE] at 2:00 P.M. with LPN #492 verified she did not perform hand hygiene between doffing and donning of gloves and should have. Review of the facility policy titled, Hand Hygiene, undated, revealed hands should be washed for at least twenty (20) seconds using soapy and water under the following conditions: L. before putting on gloves and M. after removing gloves. 3. Observation on [DATE] at 8:10 A.M. of the Dispatch Hospital Cleaner Disinfectant Towels with Bleach outside of Resident #15 and #66's room in the bottom drawer of the isolation cart. These were the disinfectant wipes to be used for cleaning protective eyewear after exiting a room with COVID-19 positive residents. Observation of the container revealed the Dispatch Hospital Cleaner Disinfectant Towels with Bleach had expired on [DATE] and even though it had bleach in it, Coronavirus was not listed as one of the viruses the disinfectant killed. Review of documentation from the internet revealed the Dispatch Hospital Cleaner Disinfectant Towels with Bleach did kill the Coronavirus. Interview on [DATE] at 8:13 A.M. with Regional RN #490 verified the wipes were expired. An assessment of all isolation carts by the Regional RN #490 revealed the Dispatch disinfectant wipes outside of Resident #22's and Resident #72's rooms were also expired. Regional RN #490 revealed the facility was pulling all the disinfectant towels from the isolation carts and will only use disposable face shields. Telephone interview on [DATE] at 9:17 A.M. with customer service personnel for the manufacturer of Dispatch disinfectant wipes revealed the Dispatch Hospital Cleaner Disinfectant Towels with Bleach did not have an extended shelf life beyond the expiration date and the efficacy could not be guaranteed for any pathogen, including COVID-19, beyond the expiration date. 4. Observation on [DATE] at 11:05 A.M. of LPN #456 obtaining a finger stick blood sugar (FSBS) from 366285 Page 16 of 17 366285 09/25/2023 Continuing Healthcare of Shadyside 60583 State Route 7 Shadyside, OH 43947

F 0880 Level of Harm - Minimal harm or potential for actual harm Resident #44. LPN #456 gathered her supplies which included two lancets (a needle device to prick the finger for a drop of blood for FSBS testing), performed hand hygiene, donned gloves and informed the resident what would be happening. She obtained the FSBS, and the reading was 343. LPN #456 informed Resident #44 she would return with his insulin to cover his elevated blood sugar. She exited the room and placed the used lancet and unused lancet in the trash can connected to the medication cart. Residents Affected - Many Interview on [DATE] at 11:14 A.M. with LPN #456 verified she discarded one used lancet and one unused lancet in the trash can connected to the medication cart. She verified that was not appropriate disposal of a lancet, especially one which had been used and had blood on it. Review of the facility policy titled, Sharps Disposal, revised 01/12, revealed the facility shall discard contaminated sharps into designated containers. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. Further review revealed contaminated sharps will be discarded into containers that are: closable, puncture resistant, leakproof on sides and bottom, labeled or color-coded in accordance with our established labeling system, and impermeable and capable of maintain impermeability through final waste disposal. 366285 Page 17 of 17