Health inspection·January 30, 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 staff interview, the facility failed to ensure resident's anticoagulant medications were accurately coded on the Minimum Data Set (MDS). This affected one resident (#81) out of 22 residents reviewed for accuracy of MDS assessments. The facility census was 106. Residents Affected - Few Findings include: Review of the Resident #81's chart revealed resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis, history of other venous thrombosis and embolism unspecified lump in unspecified breast, disorder of kidney and ureter, chronic obstructive pulmonary disease (COPD), anxiety disorder, personal history of Coronavirus (COVID-19), weakness, and hypothyroidism. Review of Resident #81's quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact and Resident #81 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #81 required supervision with eating. Further review of Resident #81's MDS revealed Resident #81 did not receive any anticoagulants during the MDS review period. Review of Resident #81's care plan reference to bleeding dated 02/01/22, revealed Resident #81 had a risk of bleeding due to the use of Eliquis (anticoagulant). Interventions included administer medications as ordered, gentle oral hygiene, monitor for signs and symptoms of bleeding and obtain and monitor laboratory (labs) results and diagnostic tests as ordered. Review of Resident #81's physician orders dated 02/28/22, revealed Resident #81 was prescribed Eliquis tablet 2.5 milligrams (mgs) give one tablet by mouth two times a day related to personal history of other venous thrombosis and embolism. Resident #81's Eliquis did not have a stop date. Interview with Corporate Nurse #800 on 01/25/23 at 10:18 A.M., verified Resident #81's Eliquis was not accurately coded as an anticoagulant on the MDS. Review of email correspondence from the Administrator on 01/26/23 at 10:24 A.M., revealed the facility did not have a policy on accurately coding the MDS. Page 1 of 15 366320 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to develop a care plan for a resident's hearing loss and the facility failed to implement a resident's falls care plan. This affected two residents (#26 and #81) out of the 22 residents reviewed for care planning. The facility census was 106. Findings include: 1. Review of the Resident #81's chart revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis, history of other venous thrombosis and embolism, unspecified lump in unspecified breast, disorder of kidney and ureter, chronic obstructive pulmonary disease (COPD), anxiety disorder, insomnia, disorder of bone density and structure, tobacco use, repeated falls, personal history of Coronavirus (COVID-19), weakness, restless leg syndrome, irritable bowel syndrome without diarrhea, and hypothyroidism. Review of Resident #81's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be cognitively intact and Resident #81 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #81 required supervision with eating. Further review of Resident #81's MDS revealed Resident #81 had one fall with major injury. Review of Resident #81's fall risk assessment dated [DATE], revealed Resident had one to two falls in the past 90 days and Resident #81 was at increased risk for falls. Review of Resident #81's fall care plan revised on 01/05/23, revealed Resident #81 was at risk for falls. Interventions included bright tape to wheelchair breaks. Observation of Resident #81 on 01/25/23 at 11:21 A.M., revealed Resident #81 to be sitting in her wheelchair in the activity room. Resident #81 did not have any bright colored tape to her wheelchair breaks and her wheelchair breaks were not engaged. Interview with Registered Nurse Unit Manager (RN) #120 on 01/25/23 at 11:21 A.M., verified Resident #81's care plan stated she was to have bright tape on her wheelchair breaks. RN Unit Manager #120 also verified Resident #81 did not have any bright tape to her wheelchair breaks while she was sitting in her wheelchair in the activity room. 2. Review of the Resident #26's chart revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD, hearing loss, acute and chronic respiratory failure with hypoxia, altered mental status, dry eye syndrome of unspecified lacrimal gland, insomnia, primary osteoarthritis, presence of right artificial knee, other psychoactive substance abuse, family history of other psychoactive substance abuse and dependence, unspecified mood disorder, major depressive disorder, primary osteoarthritis, generalized anxiety disorder, hypothyroidism, gastro esophageal reflux disease without esophagitis. Review of Resident #26's quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact and Resident #26 required limited bed mobility, dressing, toileting, and personal hygiene. Resident #26 required supervision with eating and transfers. Resident #26 had adequate hearing with no devices. 366320 Page 2 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #26's audiology visit dated 09/16/22, revealed Resident #26's hearing tests were performed. Resident #26 reported having hearing aids in the past but lost them about five years ago when she moved to the nursing home. The hearing evaluation revealed a bilateral mild to moderate hearing loss. Review of Resident #26's care plan dated 01/25/23, revealed Resident #26 did not have a care plan for hearing loss. Interview with Corporate Nurse #800 on 01/25/23 at 10:18 A.M., verified Resident #26's hearing loss documented in the 09/16/22 audiology visit was not addressed in the care plan. Review of the facility's care planning policy dated October 2022, revealed the facility will provide resident centered care aiming to provide individualized comprehensive care plans for each resident. A care plan will be developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level. 366320 Page 3 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, staff interviews, review of online resources from Medline Product review, review of online resources from Medscape, and review of the Material Safety Data Sheets (MSDS), the facility failed to ensure medications were stored and prepared for administration in accordance with acceptable professional nursing standards of practice. This affected one resident (#353) of the three residents reviewed during medication administration. The facility census was 106. Residents Affected - Few Findings Included: Review of record of Resident #353, revealed an admission date on 01/24/23. Diagnosis included, but not limited to, pneumonia, chronic obstructive pulmonary disease (COPD), hypertensive heart disease, dementia, Alzheimer's disease, malignant neoplasm of breast, and allergic Rhinitis. A comprehensive Minimum Data Set (MDS) assessment had not been completed. Review of Plan of Care dated on 01/24/23, revealed Resident #353 was at risk for altered cardiopulmonary status related to COPD, shortness of breath when lying flat, and interstitial pulmonary disease. Interventions included administer medications as ordered and assist with activity of daily living as needed. Review of the physician's orders for Resident #353 dated on 01/24/23, revealed resident was ordered to received Fluticasone-Salmeterol (bronchodilator/steroid) 232-14 micrograms aerosol powder via one puff by mouth every morning and at bedtime for chronic pulmonary disease. Physician's orders dated 01/24/23, revealed resident was ordered to receive Azelastine HCL (antihistamine) 0.1 percent solution via two sprays in both nostrils every morning and at bedtime for chronic pulmonary disease. During observation of medication administration on 01/25/23 at 8:40 A.M. with Registered Nurse (RN) #132, revealed RN #132 administered medications to Resident #353 which included Fluticasone-Salmeterol inhaler and Azelastine nasal spray. Observation immediately afterwards, revealed RN #132 returned the medication cart, removed a container of Micro-Kill disinfectant wipes, and cleaned the Fluticasone-Salmeterol inhaler and a Azelastine container of nose spray including the applicator tips of the containers. Interview on 01/25/23 at 8:55 A.M. with RN #132, revealed she cleaned all resident's inhalers and nasal sprays with the same Micro-Kill wipes. RN #132 verified she cleaned Resident #353's inhaler and nasal spray and stated she was not aware the inhalers and nasal sprays containers could not be cleaned with the Micro-Kill wipes. Interview on 01/25/23 at 9:57 A.M. with RN #120, stated she would not use the Micro-Kill wipes on a resident's nasal spray or an inhaler. Interview on 01/25/23 at 11:15 A.M. with the Director of Nursing (DON) when questioned about the staff using the Micro Kill wipes, she stated she could not comment, however, stated there was a facility policy in place that staff should follow. DON stated she did not see a concern about staff using the Micro-Kill cleaning wipes on the medication containers. DON stated that she did not have the MSDS sheets for the Micro-Kill in the facility and she would have to get the MSDS sheets faxed to her. Review of online resources from Medline, titled Micro-Kill plus disinfecting /deodorizing Cleaning Wipes with Alcohol 366320 Page 4 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (https://www.medline.com/product/Micro-Kill-Disinfecting/Deodorizing-Cleaning-Wipes-with-Alcohol/Disinfectants-Wipes/Z0 undated, revealed the wipes were intended for use on hard, nonporous surface only and they were listed as hazardous. Review of undated document titled Material Safety Data Sheet (MSDS) for Micro-Kill disinfectant wipes, indicated to avoid contact with eyes, avoid prolonged exposure, provide adequate ventilation and wear appropriate personal protective equipment (PPE) when handling. Prolonged inhalation may be harmful, exposure causes skin irritation, exposed individuals may experience tearing, redness, and discomfort. Review of undated document titled Medline - Product Right-to-Know Ingredient List for product name for Micro-Kill disinfectant wipes revealed the wipes were IRIS Neurotoxicant designated list revealed the chemicals for which a reference dose or reference concentration has been developed based on neurotoxicity in the United States Environmental Protection Agency (EPA) integrated risk information system and the chemicals identified in the wipes were identified as carcinogenic to humans or likely to be carcinogenic to humans. Review of online resources from Medscape titled Salmeterol/fluticasone inhaler (https://reference.medscape.com/drug/advair-diskus-salmeterol-fluticasone-inhaled-343448), undated, revealed to clean the actuator or mouthpiece at least once a week by gently wiping the small circular opening where the medicine is sprayed out with a clean cotton swab dampened with water. Then wipe the inside of the mouthpiece with a clean tissue dampened with water and let it air dry overnight. Review of online resources from Medscape titled azelastine (https://reference.medscape.com/drug/astelin-nasal-spray-astepro-azelastine-343414), undated, revealed to clean container once a week, by removing the dust cap, gently pull upward on the spray pump to lift away from the bottle, wash dust cap and spray pump in warm tap water and allow to dry completely. 366320 Page 5 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

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, record review, staff interview and review of facility policy, the facility failed to ensure resident's fall interventions were in place. This affected two residents (#81 and #86) out of six residents reviewed for falls. The facility census was 106. Findings include: 1. Review of the Resident #81's chart revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis, unspecified lump in unspecified breast, disorder of kidney and ureter, anxiety disorder, insomnia, disorder of bone density and structure, repeated falls, personal history of Coronavirus (COVID-19), weakness, restless leg syndrome, irritable bowel syndrome without diarrhea, and hypothyroidism. Review of Resident #81's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be cognitively intact and resident required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #81 required supervision with eating and resident had one fall with major injury. Review of Resident #81's fall risk assessment dated [DATE], revealed Resident #81 had one to two falls in the past 90 days and Resident #81 was at increased risk for falls. Review of Resident #81's fall care plan revised on 01/05/23 revealed Resident #81 was at risk for falls. Interventions included bright tape to wheelchair breaks. Observation of Resident #81 on 01/25/23 at 11:21 A.M., revealed Resident #81 to be sitting in her wheelchair in the activity room. Resident #81 did not have any bright colored tape to her wheelchair breaks and her wheelchair breaks were not engaged. Interview with Registered Nurse Unit Manager (RN) #120 on 01/25/23 at 11:21 A.M., verified Resident #81's care plan stated she was to have bright tape on her wheelchair breaks. RN Unit Manager #120 also verified Resident #81 did not have any bright tape to her wheelchair breaks while she was sitting in her wheelchair in the activity room. 2. Review of Resident #86's medical chart revealed resident was admitted on [DATE]. Diagnosis included, but not limited to, diabetes type two, urinary tract infection, major depressive disorder, anxiety disorder, acute kidney failure, chronic systolic heart failure, and dementia severity without behavioral disturbances. Review of MDS quarterly assessment dated [DATE], revealed Resident #86 had a Brief Interview of Mental Status (BIMS) of two which indicated that the resident had severely impaired cognition. Resident #86 required extensive two-person physical assistance for bed mobility, transfers, bathing, and toilet use. Resident was extensive one-person physical assistance for personal hygiene, and dressing. MDS indicated resident propelled himself in a wheelchair in the facility. MDS indicated resident had two or more falls with no major injuries. Review of plan of care dated on 01/19/23, revealed Resident #86 was at risk for falls related to 366320 Page 6 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few heart failure with Ejection Fraction (EF) estimated 30 percent (normal 50 to 75 percent), type two diabetes, protein calorie malnutrition, depression, anemia, syncope, and collapse. Resident had history of falls with thoracic (T) 12 fracture. Interventions included ensure bedding was straight and clean, initiate resident about rising and sitting slowly, assist with transfers, keep floors free from spills and clutter, encourage resident to use call light while in room, monitor blood pressure with any complaint of dizziness, notify physician of any falls, obtain and monitor laboratory (lab) results, offer and encourage rest periods, update family on any items needed, use assistive devices to transfer or ambulate resident, proper footwear in place to allow stability when standing, anti-rollbacks to wheelchair, nonskid socks at all times, offer urinal, bright tape to bathroom call light, non-skid rug to floor along bed, non-skid floor mat in bathroom, and bed in lowest position. Review of Fall Risk Scale dated on 11/25/22, revealed that Resident #86 had increased risk for falls with a score of 15.0. Resident was confined to chair for mobility. Observation on 01/25/23 at 7:40 A.M., revealed Resident #86 was seated in a wheelchair with black socks in place. Further observation revealed the socks were not a nonskid type socks. Interview on 01/25/23 at 7:50 A.M. with Licensed Practical Nurse (LPN) #33 verified Resident #86 did not have nonskid socks on or shoes in place. LPN #33 stated he was not sure if the resident was a major fall risk. Continued observation, revealed LPN #33 checked Resident #86's blood glucose and wheeled the resident back to the dining room for breakfast. Continued observations on 01/25/23 at 11:00 A.M., revealed Resident #86 was self-propelling himself in his wheelchair with the same black socks in place. Review of the fall and accident management policy dated June 2019, revealed the facility would identify patient risks of falls and other accidents. Interventions will be implemented and evaluated to reduce the risk of injuries and other accidents. 366320 Page 7 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from unnecessary psychotropic medications when the facility failed to follow physician recommendations/orders and discontinue a medication and by failing to ensure the resident had an adequate clinical indication for use regarding an antipsychotic medication. This affected two residents (#04 and #87) out of five residents reviewed for unnecessary medications. The facility census was 106. Findings include: 1. Review of the Resident #04's chart revealed Resident #04 admitted to the facility on [DATE] with diagnoses including major depressive disorder, chronic obstructive pulmonary disease (COPD) with exacerbation, congestive heart failure, acute kidney failure, atrial fibrillation, non-traumatic hematoma of soft tissue, severe persistent asthma hematoma of soft tissue, severe persistent asthma with exacerbation, Crohn's disease of both small and large intestine without complications, dysphagia, unspecified convulsions, aphasia, hyperlipidemia, hypertensive heart disease with heart failure, anemia and hypothyroidism. Review of the Resident #04's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #04 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #04 required supervision with eating. Further review of Resident #04's MDS revealed Resident #04 was on anti-depressant during the review period. Review of Resident #04's pharmacy recommendations dated 03/07/22, revealed the patient had active medication orders for amitriptyline (antidepressant) for management of depression. Notes indicated due to strong anticholinergic properties, please consider an alternative to amitriptyline for this patient. Alternatives include fluoxetine (antidepressant), sertraline (antidepressant), escitalopram (antidepressant), and venlafaxine (antidepressant). Further review of the pharmacy recommendation revealed Nurse Practitioner (NP) #802 addressed and agreed with the pharmacy recommendation on 03/29/22 with a response to discontinue to the amitriptyline and start fluoxetine 20 milligrams (mgs) daily. Review of the Resident #04's physician orders revealed Resident #04 was ordered amitriptyline 25 mgs one time a day for major depressive disorder on 03/03/22 and the medication was not discontinued until 04/06/22. Review of the Resident #04's physician orders revealed Resident #04 was ordered fluoxetine tablet 20 mgs by mouth one time a day for major depressive disorder on 04/06/22. The medication was discontinued on 04/13/22. Interview with the Director of Nursing (DON) on 01/26/23 at 9:54 A.M. verified Resident #04's pharmacy's recommendations were addressed by the NP #802 on 03/29/22 with a response to discontinue to the amitriptyline and start fluoxetine 20 mg daily. The DON also verified that Resident #04's amitriptyline 25 mgs was not discontinued, and Resident #04's fluoxetine 20 mgs was not started until 04/06/22. 366320 Page 8 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the record for Resident #87 revealed he was admitted [DATE] with diagnoses to include, but no limited to, Alzheimer's, dementia with behavioral disturbance, diabetes type 2, insomnia, hyperlipidemia, anxiety disorder, chronic kidney disease and major depressive disorder. Review of the quarterly assessment dated [DATE] for Resident #87, revealed residents Brief Interview of Mental Status (BIMS) score was nine indicating moderate cognitive impairment and he required supervision with eating, limited with bed mobility, transfers and toileting and extensive assistance with dressing and personal hygiene. There were no behaviors documented. Review of the quarterly MDS for 08/22/23 documented no behaviors. Review of the Care Plan dated 01/13/23, revealed Resident #87 had a behavior problem related to Dementia as evidenced by aggression, combative behavior, grabbing at fellow residents, wandering, impulsivity. agitation and hallucinations. Notes was non-compliant with care and medication. Further, review of his Care Plan, revealed resident used psychotropic medications of Seroquel (antipsychotic) and Depakote (mood stabilizer) related to Dementia with behaviors. Review of the physician's Orders dated 09/22/22 for Resident #87, revealed resident was ordered to receive Depakote Delayed Release 375 milligrams twice daily for behaviors. Review of the physician's orders dated 09/24/22 for Resident #87, revealed resident was ordered to receive Seroquel 50 milligrams at bedtime related to dementia with behavioral disturbance. Review of the Psychiatric (psych) note dated 12/15/22, revealed Resident #87 was being seen for a follow up visit related to his psychiatric diagnoses and medication management. Note indicated no behavioral disturbance had been reported lately although he could be non-compliant at times. Documentation revealed he was confused but able to be redirected. During an interview on 01/26/23 at 9:48 A.M. with the facilities Nurse Practitioner (NP) (#804), she reported Depakote should be given for mood disorder and not for dementia with behaviors as listed in the Physician's Orders. NP #804 also verified Seroquel was not an appropriate medication for dementia with behaviors and should be changed to another medication. NP #804 acknowledged there was not a lot of documented evidence of behavioral concerns for Resident #87. During an interview on 01/26/23 at 10:00 A.M. with a Licensed Practical Nurse (LPN #24) she reported Resident #87's medications were effective with minimal breakthrough behaviors that could be managed by non-pharmacological techniques. Review of the Behavior Monitoring data for Resident #87 from admission on [DATE] to present revealed there were only four incidents (01/02/23, 01/13/23, 01/17/23, and 01/24/23) where behaviors were noted and the behaviors were able to be redirected. Review of the facility's anti psychotropic medication management policy dated October 2017 revealed clinicians will use psychotropic medications appropriately and will ensure appropriate use, evaluation, and monitoring. 366320 Page 9 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review, staff interview, and review of faciliyt policy, the facility failed to ensure food items were maintained in a sanitary manner. This affected all residents except Resident #75 and Resident #251 that were no food by mouth. The facility census was 106. Findings include: Observation of the kitchen on 01/23/23 at 8:12 A.M., revealed there to be food debris on the edge of the fryer and in the oil of the fryer that were brown in color. Observation of the reach in refrigerator in the kitchen, revealed there to be an open and undated bag of provolone cheese, an open and undated plastic tub of vegetable base, an open and undated plastic tub of beef base on the first shelf, a half-full plastic cup of iced coffee with a straw in it that was not labeled, dated or covered, two full plastic cups of ice coffees that were not labeled, dated or covered, an opened and updated bottle of soda on the second shelf and a opened package of diced bacon that was not labeled or dated and a plastic container kitchen of boiled eggs that were not labeled or dated. Continued observation of the bread rack, revealed two loaves of wheat bread with an expiration date of 01/18/23, two loaves of white bread with an expiration date of 01/20/23, nine packs of white buns with an expiration date of 01/18/23, five packs of white buns with an expiration date of 01/12/23, and one open pack of white buns with an expiration date of 01/18/23. Interview with Food Service Assistant (FSA) #801 on 01/23/23 at 8:12 A.M. verified there to be food debris on the edge of the fryer and in the oil of the fryer that were brown in color. FSA #801 confirmed the fryer was not used on 01/23/23. FSA #801 verified there to be an open and undated bag of provolone cheese, an open and undated plastic tub of vegetable base, an open and undated plastic tub of beef base on the first shelf, a half full plastic cup of iced coffee with a straw in it that was not labeled, dated or covered, two full plastic cups of ice coffees that were not labeled, dated or covered, a opened and updated bottle of soda on the second shelf and a opened package of diced bacon that was not labeled or dated and a plastic container of boiled eggs that were not labeled or dated in the reach in refrigerator. FSA #801 also verified there to be two loaves of wheat bread with an expiration date of 01/18/23, two loaves of white bread with an expiration dated if 01/20/23, nine packs of white buns with an expiration date of 01/18/23, five packs of white buns with an expiration date of 01/12/23, and one open pack of white buns with an expiration date of 01/18/23 on the bread rack. Review of the facility's undated list of residents that were no food by mouth revealed resident (#75 and #251) did not receive any food by mouth. Review of the facility's food storage policy dated January 2019 revealed food storage areas will be maintained in a clean, safe, and sanitary manner. All leftovers will be labeled, dated, and covered. 366320 Page 10 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

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 record review, observations, staff interviews, review of facility policy, and review of Centers for Disease Control (CDC) recommendations, the facility failed to ensure glucometers were cleaned after usage. This affected 19 residents (#54, #15, #31, #55, #47, #10, #57, #37, #11, #20, #46, #83, #73, #74, #45, #86, #61, #25, and #13) who received medications from the 2400 hall medication cart. The facility also failed to ensure staff's personal belongings were not stored in the medication carts. This affected 17 residents (#70, #62, #252, #39, #75, #27, #22, #30, #81, #68, #77, #26, #5, #3, #201, #82, and #88) who received medications from the 1200 hall medication cart. Facility Census was 106. Residents Affected - Some Findings Included: Review of record for Resident #86 revealed the resident was admitted on [DATE]. Diagnosis included, but not limited to, diabetes, urinary tract infection, major depressive disorder, anxiety disorder, acute kidney failure, chronic systolic heart failure, and dementia. Review of quarterly Minimum Data Set (MDS) assessment on 11/15/22, revealed Resident #86 had a Brief Interview of Mental Status (BIMS) of 02 which indicated the resident was severely cognitively impaired. Observation of medication administration on 01/25/23 at 7:51 A.M. with Licensed Practical Nurse (LPN) #33 for the 2400 hall, revealed LPN #33 removed a glucometer from the 2400 hall medication cart, entered Resident #86's room and checked Resident #86's blood glucose. Continued observation, revealed LPN #33 completed the blood glucose check, returned to the cart with the glucometer, and placed the contaminated glucometer in the cart without cleaning. Observation revealed there were no cleaning wipes available in the cart to utilize. Interview on 01/25/23 at 8:55 A.M. with LPN #33 verified he placed the contaminated glucometer in the 2400 hall medication cart without cleaning it. Observation of the 1200 Hall medication cart on 01/25/23 at 10:03 A.M. with LPN #98, Assistant Director of Nursing (ADON) #10, and Centers for Medicare and Medicaid Services (CMS) surveyor, revealed a black sweater lying on top of resident's medications and medical supplies and a coffee mug belonging to LPN #98 in the bottom right drawer. Interview at the same time with LPN #98 and ADON #10 verified LPN #98's personal items being stored in the medication cart along with resident's medications and medical supplies. Continued observation, revealed LPN #98 removed the coffee mug and drank from it. Interview on 01/25/23 at 10:16 A.M. with ADON #10, stated the facility did not allow drinks or personal items to be stored in the medication carts and personal items should not be stored in the medication carts. Review of Infection Prevention and Control Program revised on 10/2022, revealed that the facility will maintain, and infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Review of CDC Infection Prevention, (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html), during glucose monitoring and insulin administration revealed whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected 366320 Page 11 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0880 after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 366320 Page 12 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the Resident #04's medical chart revealed Resident #04 was admitted to the facility on [DATE] with diagnoses including COPD, CHF, acute kidney failure, atrial fibrillation, non-traumatic hematoma of soft tissue, severe persistent asthma hematoma of soft tissue, severe persistent asthma with exacerbation, Crohn's disease of both small and large intestine without complications, dysphagia, unspecified convulsions, aphasia, major depressive disorder, hyperlipidemia, hypertensive heart disease with heart failure, anemia and hypothyroidism. Residents Affected - Some Review of Resident #04's quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact and Resident #04 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #04 required supervision with eating. Review of Resident #04's undated Influenza and Pneumococcal Vaccination Consent form revealed Resident #04 was allergic to shot and the box was checked stating I do not wish to have either pneumococcal vaccine administered to the aforementioned resident, and I have received the vaccinate information sheet. Resident #04 did not sign the consent. Survey team requested the Pneumonia line list, consent/declinations for sampled residents, and pneumonia policy on 01/25/22 at 4:00 P.M., again on 01/26/22 at 11:54 A.M., 12:57 P.M., and 1:30 P.M. Consents as described above were provided, however, no line list was provided. Interview on 01/26/23 at 11:41 A.M. with Assistant Director of Nursing (ADON) #10 verified Resident #04's undated influenza and pneumococcal vaccination consent form was not signed. Interview on 01/26/23 at 11:54 A.M. with Registered Nurses (RN) (#10 and #112), stated that there was a vaccination log for residents. RNs (#10 and #112) were uncertain as to when the updated pneumonia vaccinations were audited or offered to residents on an annual basis to ensure compliance. Interview with Resident #04 on 01/26/23 at 1:24 P.M., revealed Resident #04 did not want the pneumococcal vaccine due to him having an allergic reaction to it. Resident #04 stated that he was educated on the different pneumococcal vaccines and understood the risk and benefits but did not want the vaccine. Interview on 01/26/23 at 2:24 P.M. Director of Nursing (DON) verified Pneumonia Policy, undated and without review dates listed, was the most recent policy the facility had in place. DON verified that consents were as described, with older consent forms including the PCV13, PCV15, PCV20, AND PPSV23 vaccinations, but the consent dated 10/20/22 did not include PCV15 or PCV20. Review of online resources from CDC (https://www.cdc.gov/media/releases/2022/s1020-immunization-vote.html) revealed on 10/20/22, the Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) recommended updated immunization schedules and program guidance to be published in early 2023, which included updated pneumonia vaccinations for individuals over the age of 65. Review of online resources from CDC (https://www.cdc.gov/vaccines/acip/recommendations.html), the recommended pneumonia vaccinations for individuals over the age of 65 were: Shared clinical decision-making is recommended regarding administration of PCV20 for adults aged older than 65 years who completed their vaccine series with both PCV13 and PPSV23. If a decision to administer PCV20 is made, a 366320 Page 13 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0883 dose of PCV20 is recommended at least 5 years after the last pneumococcal vaccine dose. Level of Harm - Minimal harm or potential for actual harm Review of online resources from CDC (https://www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm) revealed that for individuals over the age of 65 were recommended to receive one dose of PCV20 or one dose of PCV15 followed by a dose of PPSV23 one year later. These recommendations were approved for use beginning 10/24/22. Residents Affected - Some Review of the pneumococcal vaccine policy dated October 2022, revealed each resident or resident's representative receives education regarding the benefit and potential side effects of the immunization. Each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. The resident or the resident representative has the opportunity to refuse the immunization. The medical record includes documentation that at minimum indicates that the resident or resident representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization and the resident either received the pneumococcal immunization or if the resident did not receive the pneumococcal immunization due to medical contraindication or refusal. If the resident has not received previous immunization, the consent and denial form will be signed, and the physician order will be obtained. Based on interviews, record review, review of facility policy and review of online resources from the Centers for Disease Control (CDC), the facility failed to monitor and ensure residents were up to date on pneumonia vaccinations and facility failed to ensure their pneumonia policy was updated annually. This affected four of five residents (#4, #69, #84, and #87) reviewed for immunizations. Facility census was 106. Findings include: 1. Review of medical records for Resident #69 revealed an admission date of 02/16/21 with congestive heart failure (CHF). Review of the MDS assessment dated [DATE], revealed resident had severe cognitive impairment. Review of the immunizations for Resident #69, revealed resident received the Pneumococcal Polysaccharide Vaccine (PPSV23) on 04/27/00 and was due for another pneumonia vaccination at time of admission to the facility. Medical records revealed no declination/consent form being present in resident's hard chart. Review of Influenza-flu and Pneumococcal-Pneumonia vaccination Consents dated 09/29/22, revealed Resident #69 was offered Pneumococcal Conjugate Vaccine (PCV 13), Valent Pneumococcal Conjugate Vaccines (PCV15 and PCV20), and PPSV23 Pneumonia vaccinations, which were declined by residents representative. Resident #69's representative consented to the influenza and the influenza consent was marked I wish to receive. Notes indicated the pneumonia vaccination was not offered on this consent. The consents were signed and dated in two different handwritings. 2. Review of records for Resident #84 revealed an admission date of 03/31/22 with diagnosis of COPD. Review MDS assessment dated [DATE], revealed resident had severe cognitive impairment. Review of the immunization records for Resident #84, revealed no pneumonia vaccine information was available. Notes indicated Resident #84 was due for a pneumonia vaccination upon admission to the facility. Further review of medical records revealed no declination/consent form was present in resident's hard chart. 366320 Page 14 of 15 366320 01/30/2023 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of records for Resident #87, revealed an admission date of 06/16/22 with chronic renal failure. Review of MDS assessment dated [DATE], revealed Resident #87 had moderate cognitive impairment. Review of the immunizations for Resident #87, revealed resident received the PCV13 vaccination on 01/02/14 and was due for PPSV23 or PCV20 at time of admission to the facility. Further review of the medical chart revealed no declination/consent form was present in resident's hard chart. Review of Influenza-flu and Pneumococcal-Pneumonia Vaccination Consents dated 07/16/22, revealed Resident #87 was offered PCV13, PCV15, PCV20, and PPSV23 pneumonia vaccinations, which were declined and the influenza consent was marked not applicable. Review of Influenza-Flu vaccination Consents dated 09/29/22, revealed Resident #87 consented to the influenza vaccination and the pneumonia vaccination was not offered on this consent form. 366320 Page 15 of 15