Health inspection·July 21, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure dependent residents were fed timely. This affected four residents (#50, #26, #11 and #56) of six residents who were dependent on staff for eating. The facility census was 76. Findings included: 1. Review of the medical record for Resident #50 revealed an admission date of 12/09/16. Diagnosis included vascular dementia, cerebral vascular attack (CVA) with hemiplegia affecting right dominant side, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had severely impaired cognition and required extensive assistance of one to assist with eating. Review of the plan of care for Resident #50 revealed the resident had nutritional problems related to history of CVA, dysphagia of oropharyngeal phase, advanced dementia, required a mechanically altered diet with thickened liquid, had an activities of daily living (ADL) self-care performance deficit and was dependent or required extensive assistance with ADLS due to cognitive and functional deficit and diseases process. Interventions required for resident to be fed during dining. Review of the physician orders for Resident #50 dated 04/14/20 revealed resident was ordered a regular diet pureed texture and honey consistency. Review of the dietary assessment notes for Resident #50 dated 06/22/22, indicated Resident #50 was ordered a regular pureed diet nectar thick liquid and was dependent for feeing. 2. Review of the medical records for Resident #26 revealed an admission date of 11/01/20. Diagnosis included dementia, diabetes mellitus (DM), dysphagia, diabetic retinopathy, and congestive heart failure (CHF). Review of the MDS assessment dated [DATE] revealed Resident #26 had severely impaired cognition, required extensive assistance of one to assist with eating. Review of the plan of care for resident revealed Resident #26 had nutritional problems related to history of DM, CHF, dementia, insidious weight loss and dysphagia. Interventions required for resident to be monitored during meal intake, provide assistance with meal, observe for sign symptoms aspiration, dysphagia, choking and coughing. Page 1 of 22 366389 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician orders for Resident #26 dated 06/28/22 revealed resident was ordered a consistent carbohydrate diet (CCD) regular texture thin consistency and supervision required setup and attention to task. Review of the dietary assessment notes for Resident #26 dated 05/31/22 indicted resident was ordered regular diet, think liquid, and required supervision during meals. 3. Review of the medical records for Resident #11 revealed an admission date of 09/20/18. Diagnosis included dysphagia, CVA, cerebral infarction, osteoarthritis, lack of coordination, muscle weakness, Alzheimer's disease late onset, and psychotic disorder with hallucinations. Review of the MDS assessment dated [DATE] revealed Resident #11 had severely impaired cognition, required extensive assistance of one to assist with eating. Review of the plan of care for resident revealed Resident #11 had an ADL self-care performance deficit, required assistance with ADLs due to decreased mobility and cognitive impairment, and resident had nutritional problem related to history of CVA, dementia, dysphagia, mechanically altered diet, and prescribed diuretic. Interventions required for resident to be fed for all meals. Review of the physician orders for Resident #11 dated 07/16/21 revealed resident was ordered regular diet, puree texture, nectar consistency. Review of the dietary assessment notes for Resident #11 dated 06/13/22 indicated resident was ordered regular diet, pureed with nectar thickened liquids and resident was noted to be dependent on staff for feeding. 4. Review of the medical record for Resident #56 revealed an admission date of 08/06/21. Diagnosis included dysphagia, metabolic encephalopathy, CVA with hemiplegia, unspecified glaucoma, Parkinson's disease, muscle weakness, abnormal involuntary movements, and lack of coordination. Review of the MDS assessment dated [DATE] revealed Resident #56 had moderately impaired cognition and required extensive assistance of one to assist with eating. Review of the plan of care for Resident #56 revealed resident had nutritional problems related to history of CVA with paraplegia, Parkinson's Disease, significant weight loss, dysphagia, facial droop, aphasia, and dependent feed with mechanically altered diet. Interventions required resident to be provided meals as ordered, assisted with meals, and monitor meal intake, and observe for signs and symptoms of aspiration. Review of the physician orders for Resident #56 dated 05/11/22 revealed resident was ordered regular diet, soft diet texture, thin consistency, and required supervision and assistance for all meals. Review of the dietary assessment notes for Resident #56 dated 05/19/22 indicated resident was ordered regular soft texture, thin liquids and resident was dependent on staff for feeding. Observation on 07/13/22 at 7:46 A.M. revealed an unknown dietary staff member delivered the breakfast trays to the floor and placed the tray cart directly in front of the nurse's desk and immediately exited the area. Observation at the same time revealed Residents (#12, #50, #29 and #69) were seated around the nurse's desk in middle of hallway. 366389 Page 2 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 07/13/22 at 7:53 A.M. revealed Staff #60 removed trays from the cart and placed breakfast trays in front of Residents (#29, #50, and #69) and then placed a tray for Resident #12 behind a partitioned wall in the kitchenette area across from the nurse's desk. Residents (#29 and #69) immediately started eating while Residents (#50 and #12) sat around the nurse's desk as they watched the other residents eating. STNA #60 was observed to tell Residents #12 and #50) she would be back in a bit and continued with delivering trays. Observations on 07/13/22 at 8:10 A.M. revealed staff STNA #60 delivered breakfast tray to Resident #26's room and placed tray on the bed side table and immediately exited room. Surveyor observed STNA state, I will be back in a bit. Observation at same time revealed STNA #13 delivered tray to Resident #56's room and immediately exited room. Observations on 07/13/22 at 8:12 A.M revealed STNA #60 delivered tray to Resident 72's, placed tray on bed side table and immediately exited room. Observations on 07/13/22 at 8:17 A.M. revealed Residents (#26, #72 and #56) had their breakfast trays in front of them in their rooms and no staff assisting with feeding, and Resident #50 was still seated at the nurse's desk with her tray in front of her and without being fed. Observations on 07/13/22 at 8:18 A.M. reveled STNA #60 entered Resident #72's room and started to feed the resident. Interview with STNA #60 at same time indicated she always fed Resident #72 first due to the family's request. STNA #60 indicated she had three Residents (#50, #26 and #72) who were dependent on staff to feed and could only feed one at a time since they were all in different areas of the hall. STNA #60 stated she normally fed Resident #72, then Resident #26 then Resident #50 who was normally seated at the nurse's station. STNA #60 stated Resident #26 was alert enough to not eat his food sitting on his bed side table. STNA #60 additional stated she had two Residents (#69 and #41) who required supervision at meals due to choking/aspiration risk. STNA #60 stated she was the only STNA on the 600 hall and could not feed three residents, provide supervision for two and complete other resident tasks at the same time. STNA #60 stated this staffing schedule was a normal routine for the hallway. Interview with STNA #13 on 07/13/22 at 8:26 A.M. indicated she was the only STNA for the 600 hall and had two Residents (#11 and #56) who were dependent for being fed and two Residents (#65 and #12) who required supervision during meal due to choking / aspiration risk. STNA #13 stated she normally fed Resident #56 in her room then fed Resident #11 at the nurse's desk. STNA Indicated Resident #11 preferred to eat at the nurse's desk, but Resident #65 preferred to eat in her room. STNA #13 stated Resident #11 was normally out of bed and placed at the nurse's desk to eat, but she had not had time to get resident up and out of bed so she left Resident #11's tray in the tray cart until she could get her up and out of bed. STNA #13 stated she was not able to feed two dependent residents, supervise two residents eating as well as taking care of other resident tasks at the same time. STNA #13 verified the above and stated the staffing schedule was a normal routine for the halls. Observation on 07/13/22 at 8:27 A.M. revealed STNA #16 arrived on the and STNA #16 immediately sat next to Resident #50 and started to feed her. Interview with STNA #16 at same time indicated she was the whole house aide and was told she needed to feed the resident. STNA #16 stated she was not aware Resident #16 needed fed. Observation at 8:32 A.M. revealed STNA #60 exited Resident #72's room. Interview at same with time with STNA #60 indicated she had completed feeding Resident #72 and was going to feed Resident #26. 366389 Page 3 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0550 Level of Harm - Minimal harm or potential for actual harm At 8:33 A.M. revealed Resident #26's covered tray was still situated in front of the resident on the bedside table as STNA #60 entered and started to feed Resident #26. Observation on 07/13/22 at 8:34 A.M. revealed Residents #56's breakfast tray was still sitting on her bedside table in front of resident. Residents Affected - Some Observation on 07/13/22 at 8:37 A.M. revealed STNA #13 arrived at Resident #56's room to feed her. Interview with STNA #13 at same time indicated she had to complete other tasks for residents before she could feed Resident #56. STNA #13 verified residents' trays had been sitting in front of her with no staff to feed resident and verified the above information. STNA #13 additionally stated as soon as she completed feeding Residents #56, she would get Resident #11 out of bed and feed her. STNA #13 verified Resident #11 should have been out of bed but due to having only one staff member on the floor, she was not able to complete all her morning tasks. Interview with Staff #92 on 07/13/22 at 8:55 A.M. verified she was not aware resident's trays had been sitting in front of them and her expectations were for staff to feed all dependent residents in a timely manner and supervise those who required supervision. Staff #92 indicated she was not aware Resident #11 was still in bed and needed to be assisted up. Staff #92 said Resident #11 preferred to be up in a Geri Chair and eating at the nurse's desk. Staff #92 indicated for breakfast service, residents ate on their units and in their rooms, but for lunch service, residents had the option of going to the dining room to eat. Observation on 07/13/22 at 9:00 A.M. revealed Staff #92 feeding Resident #11 in her room. Review of the policy titled Resident Rights dated 05/30/19 revealed the residents would be treated with dignity and respect and facility would provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the resident. 366389 Page 4 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

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 medical record review, staff and resident interview, review of the bed hold authorization form, and policy review, the facility failed to notify residents who were discharged to the hospital of the bed hold payment policy. This affect two residents (#03 and #53) out of five residents reviewed for hospitalizations. The facility census was 76. Findings include: 1. Review of the medical record revealed Resident #03 was admitted on [DATE], discharged to the hospital on [DATE]. Diagnosis included chronic kidney disease, urinary tract infection and asthma with exacerbation. The resident was listed as the responsible party. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and required extensive assistance with Activity of Daily Living skills. Review of the nurses note dated 03/25/22 at 2:18 P.M. verified the resident was sent to the hospital via emergency squad. Review of the bed hold authorization form dated 03/25/22 and listing Resident #03 revealed no signature of the Resident #03. The Regional Business Office Manager (RBOM) #96 signed and dated the form on 03/25/22 and indicated the telephone contact request was not to hold the bed. No telephone contact name information had been listed on the form. There was no indication a certified letter had been mailed. 2. Review of the medical record revealed Resident #53 was admitted on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. Diagnosis included multiple fractures, hypertension, depression, hemoperitoneum and sepsis. The resident was listed as the responsible party and one person listed as an emergency contact. Review of the admission MDS dated [DATE] revealed the resident had intact cognition and required extensive assistance with Activity of Daily Living skills. Review of the nurses note dated 06/03/22 at 6:12 P.M. verified the resident was sent to the hospital via emergency squad. Review of the bed hold authorization form dated 06/04/22 and listing Resident #53 revealed no signature of Resident #53. The RBOM #96 signed and dated the form on 06/04/22 and indicated the request was not to hold the bed. No telephone information had been completed on the form. There was no indication a certified letter had been mailed. Interview on 07/11/22 at 2:06 P.M. Resident #53 stated she had not been informed of holding a bed when she went to the hospital on [DATE]. She denied a family representative had been notified of a policy to hold a bed. Interview on 07/13/22 at 2:43 P.M. Regional Clinical Nurse #97 verified no additional paperwork was available to verify a bed hold notice had been provided to the resident with 24 hours of transfer 366389 Page 5 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0625 to the hospital. Level of Harm - Minimal harm or potential for actual harm Interview on 07/14/22 at 10:06 A.M., RBOM #96 verified she had signed Resident #53's bed hold notification form on 06/04/22 and the Resident #53 had not received or signed the bed hold notification for the hospitalization of 06/03/22. RBOM #96 verified Resident #03 bed hold authorization form of hospitalization 03/25/22, had no resident signature or information of the telephone contact. RBOM #96 verified no certified return mail receipt the notification had been mailed for Residents #03 and #53. Residents Affected - Few Review of the facility policy titled Bed Hold Policy', dated 02/17/17, revealed in the event a resident returns to the hospital, the designee will notify the resident and/or responsible party of the days available within 24 hours of the patient leaving the facility or the following business day, if the patient leaves on the weekend. If the bed hold authorization form cannot be signed prior to the resident leaving and needs to be mailed, it must be mailed certified return receipt by the Business Office Manager. 366389 Page 6 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review, observation, staff interview, review of the meal tickets, and policy review, the facility failed to ensure staff provided adequate supervision during meals. This affected four residents (#12, #69, #41 and #65) out of four residents who required supervision during meals. The facility census was 76. Findings include: 1. Review of medical records for Resident #69 revealed an admission date of 04/08/19. Diagnosis included respiratory failure, dysphagia, congestive heart failure, muscle weakness, lack of coordination, hallucinations, dementia with behaviors, psychosis Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had severely impaired cognition, was a set up only and required supervision with eating. Review of the physician orders for Resident #69 dated 09/05/19 indicated resident was ordered a regular diet regular texture and thin consistency. Review of the speech therapy notes for Resident #69 dated 12/21/21 indicated the resident had been discontinued from speech therapy and discharge instructions included resident required supervision for oral intake due to potential risk for aspiration and malnutrition. Review of the dietary nutrition assessment dated [DATE] revealed Resident #69 had history of dysphagia and required supervision for all dining. Review of the plan of care for Resident #69 had a nutritional problem due to history of CHF, dementia, depression, and dysphagia. Interventions included monitor meal intake, observe for sign and symptoms of aspiration, dysphagia, (i.e., choking, coughing, pocketing food, loss of liquids, solids from mouth when eating, drinking difficulty or pain when swallowing). 2. Review of the medical record for Resident #12 revealed an admission date of 04/06/21. Diagnosis included acute respiratory failure, weakness, dysphagia oropharyngeal phase and malnutrition. Review of the MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition was one person assist and required supervision with eating. Review of the physician orders for Resident #12 dated 04/14/22 indicated the resident was ordered a regular diet, puree texture thin consistency, with no straws and a five milliliter (mL) Provale cup at all meals. Review of the dietary nutrition assessment for Resident #12 dated 04/21/22 revealed the resident was ordered regular pureed diet with thin liquids, RD was not able to comprehend or have conversation with resident, resident had signs and symptoms of possible swallowing disorder, had loss of liquids/solids from mouth when eating or drinking, and used adaptive equipment and required supervision during meals. 366389 Page 7 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the speech therapy notes for Resident #12 dated 05/23/22 indicated the resident had been discontinued from speech therapy and discharge instructions included resident required supervision for oral intake due to potential risk for aspiration and malnutrition. Review of the plan of care for Resident #12 revealed resident had nutrition problems related mechanically altered diet, swallowing disorder, used adaptive equipment and was non-verbal. Interventions included monitor meal intake, observe for sign and symptoms of aspiration, dysphagia, (i.e., choking, coughing, pocketing food, loss of liquids, solids from mouth when eating, drinking difficulty or pain when swallowing). 3. Review of the medical record for Resident #65 revealed an admission date 04/22/22. Diagnosis included chronic cough, dysphagia, chronic kidney disease, lung cancer, osteoarthritis, and abnormal movements. Review of the MDS assessment dated [DATE] revealed Resident #65 had severely impaired cognition, was set up only and required supervision for eating. Review of the physician orders for Resident #65 dated 05/02/22 revealed the resident was ordered regular diet, soft texture thin consistency. Review of the dietary nutrition assessment for Resident #65 dated 05/04/22 revealed the resident was ordered a regular, soft diet with ground meat and required supervision. Review of the plan of care for Resident #65 indicated resident had altered nutrition status due to lung cancer with hospice care, low body weight, sore spot-on gum from dentures, required a mechanically altered diet related to esophageal stricture. interventions included position resident properly for eating/swallowing, provide assistance with meals as needed, staff to monitor and cue as needed to take small bites and swallow bites prior to taking another bite, monitor meal intake, observe for sign and symptoms of aspiration, dysphagia, (i.e., choking, coughing, pocketing food, loss of liquids, solids from mouth when eating, drinking), and difficulty or pain when swallowing. 4. Review of medical record for Resident #41 revealed an admission date of 05/24/22. Diagnosis included cerebral infarction, dysphagia, diabetes mellitus, dementia, weakness, colitis, syncope, and collapse. Review of the MDS assessment dated [DATE] revealed Resident #41 had severely impaired cognition, was one-person physical assist and required supervision for eating. Review of the physician orders for Resident #41 dated 05/30/22 revealed the resident was ordered a consistent carbohydrate diet (CCD) dysphagia mechanical texture nectar consistency and required supervision for meals. Review of the dietary nutrition assessment for Resident #41 dated 06/05/22 revealed the resident had diet order of CCD, dysphagia mechanical soft nectar thick liquids, was edentulous, and required supervision for dining. Review of the speech therapy notes for Resident #41 dated 06/28/22 revealed the resident was discontinued from services and was ordered close supervision during meals due to aspiration risk. 366389 Page 8 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the meal ticket for Resident #41 dated 07/12/22 indicated resident was provided with a CCD mechanical soft diet. Review of the plan of care for Resident #41 revealed had altered nutrition status due to mechanically altered diet, chewing issues related to edentulous, CVA and dementia, and resident had an ADL self-care performance deficit. Interventions included set up and assistance with eating, monitor meal intake, observe for sign and symptoms of aspiration, dysphagia, (i.e., choking, coughing, pocketing food, loss of liquids, solids from mouth when eating). During observation on 07/12/22 at 8:13 A.M. revealed four Residents (#29, #50, #11 and #69) were seated around the nurse's desk in the center of the halls. Residents #29 and #69 were feeding themselves and Resident #12 was observed seated behind a five foot height partitioned wall of kitchenette feeding himself and there was no staff present in the area or in the hallways. Review of the meal ticket for Resident #12 at same time revealed the resident required supervision with meals. Observation revealed Resident #12 was eating biscuits gravy and eggs from a divided plate, weighted spoons as he sat in a wheelchair behind the partitioned wall. Interview with the Licensed Practical Nurse (LPN) #15 on 07/12/22 at 8:15 A.M. verified Residents (#12 and #69) were eating at the nurse's station without direct staff supervision and verified they were ordered to be supervised by staff while eating due to aspiration risk. LPN #15 additionally stated she was the nurse for the 500 and 600 halls and had 24 residents to care for and she was busy doing diabetic checks, administering medications and was not able to assist with feeding or providing direct supervision to residents eating. LPN #15 additionally stated she had a total of five Residents (#50, #26, #72, #11 and #56) who were dependent on staff for feeding and four Residents (#69, #12, #65, and #41) who required direct supervision during meals. Observation revealed STNAs (#17 and #74) were in Resident #25's room with the door shut. LPN #15 asked STNAs why Residents (#12 and #69) were not being supervised and STNAs indicated they were providing personal care for Resident #25 who was going out to an appointment. LPN #15 verified Residents (#12 and #69) were not being supervised as they ate. Interview with STNA #17 on 07/12/22 at 8:18 A.M., indicated she had three Residents (#72, #26 and #50) who were dependent on staff for eating and two Residents (#69 and #41) who required direct staff supervision. Interview with STNA #74 at same time indicated she had two Residents (#11 and #56) who were dependent on staff for eating and two Residents (#12 and #65) who required direct staff supervision. STNAs (#17 and #74) verified Residents (#12 and #69) were eating unsupervised. Continued observation at 819 A.M. revealed STNA #17 delivered a tray to Resident #41, placed tray on bedside table, called residents name, and immediately exited the room. Observation at 8:20 A.M. revealed STNA #74 arrived at nurses' desk and started feeding Resident #11. Observation at 8:21 AM revealed STNA #17 placed try in front of Resident #50 at nurses' desk and continued passing trays. Interview with STNA #17 at 07/12/22 8:30 A.M. verified she left Resident #41's tray on his bedside table. STNA #17 verified Resident #41 needed supervised but stated she had to finish delivering trays and then had to feed Resident #50 and was not able to sit in the room to supervise. Observation immediately afterwards, revealed STNA #17 sat next to Resident #50 at the nurse's desk and started to feed Resident #50. Subsequent interview with STNA #17 at 07/12/22 8:36 A.M. verified Resident #65 was delivered a tray and ate in her room unsupervised. STNA #17 verified resident was to be supervised during meals due to choking aspiration risk and stated she had to feed #50 and could only do one thing t a time. 366389 Page 9 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with LPN #15 on 07/12/22 at 8:37 A.M. verified Residents (#41 and #65) were eating in their rooms unsupervised. Observation on 07/13/22 at 7:44 A.M. revealed Resident #12 was sitting in his wheelchair at the nurse's station eating oatmeal pies with a regular cup and juice and no staff observed in area or in hallways. Continued observation at 7:46 A.M. revealed a dietary staff member delivered the breakfast trays to the floor and placed tray cart directly in front of the nurse's desk and immediately exited the area. Observation at same revealed Residents (#12, #50, #29 and #69) were seated around the nurse's desk. Observations on 07/13/22 at 7:53 A.M. revealed Staff #60 removed breakfast trays from the cart and placed breakfast trays in front of Residents #29, #50, #69 and then placed a tray for Resident #12 behind the partitioned wall in the kitchenette area across from the nurse's desk. Residents #29 and #69 immediately started eating while Residents (#50 and #12) sat around the nurse's desk as they watched the other residents eating. STNA#60 was observed to tell Residents (#12 and #50) she would be back in a bit and exited the area and continued with delivering trays to the 600 halls. Observations at same time revealed LPN #55 was in and out of resident's rooms administering glucose checks and medications and not visible in the hallway to observe residents eating at the desk. Observations on 07/13/22 at 8:09 A.M. revealed STNA #60 delivered and set up Resident #41's tray on his bed side table in his room and immediately exited the room. Observations on 07/13/22 at 8:10 A.M. revealed Resident #12 was moved behind the partitioned wall of the kitchenette by STNA #13 and situated in front of his tray. Observation revealed STNA #13 immediately exited the area and continued passing trays. Observations on 07/13/22 at 8:18 A.M. revealed Resident #41 eating breakfast in his room and unsupervised. Interview with STNA #60 at same time indicated she always fed Resident #72 in his room due to the family's request and could not feed residents and supervise residents. STNA #60 additionally stated she had two Residents (#69 and #41) who required supervision at meals due to choking/aspiration risk. STNA #60 stated she was the only STNA on the hall and could not feed three residents, provide supervision for two and complete other resident tasks by herself. STNA #60 verified Residents (#41 and #69) were unsupervised as they ate. Interview with STNA #13 on 07/13/22 at 8:26 A.M., indicated she had two Residents (#11 and #56) who were dependent on staff to feed and two Residents (#12 and #65) who required supervision during meals due to choking /aspiration risk. STNA #13 stated Resident #12 normally sat in the kitchenette area and Resident #65 preferred to eat in her room. STNA #13 stated she was the only STNA assigned to the 600 hall and stated she was not able to feed two residents and supervise two at the same time due to residents being in different areas of unit. Observation on 07/13/22 at 8:27 A.M. revealed STNA #16 and LPN #92 arrived on the hall. Observation revealed STNA #16 sat at the nurses desk and started feeding Resident #50. Interview with LPN #92 at same time indicated Resident #12 was to be supervised during meals and verified he had been eating unsupervised in the kitchenette. Observations on 07/13/22 at 8:35 A.M. revealed Residents (#41 and #65) continued eating in their rooms unsupervised. 366389 Page 10 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with LPN #55 on 07/13/22 at 8:38 A.M., indicated if a resident was ordered to be supervised during meals, then it meant for staff to have direct observation of the residents. Observations on 07/13/22 at 8:40 A.M. revealed Resident #65 continued eating in her room unsupervised. Observation at same time revealed LPN #92 waked in room and verified Resident #65 was ordered to be supervised and verified the resident ate in her room without staff presence. LPN #92 indicated she was not aware residents were eating unsupervised and stated her expectations were for staff to provided direct supervision during meals. LPN #92 verified residents ate in their rooms unsupervised. Review of the facility policy titled Eating, undated revealed under the section titled ADL Self-Performance Coding Definitions, supervision was defined as oversight, encouragement, or cueing was provided. 366389 Page 11 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of the hospital continuity of care form, and policy review, the facility failed to monitor and provide interventions for a resident with weight loss. This affected one resident (#57) out of four residents reviewed for nutrition. The facility census was 76. Residents Affected - Few Findings included: Review of the medical record for Resident #57 revealed an admission date of 07/22/21. The resident had hospitalizations from 11/30/21 to 12/01/21, 01/07/22 to 01/11/22, and 03/22/22 to 03/24/22. Diagnoses included paraplegia, type two diabetes mellitus, muscle weakness, cognitive communication deficit, hypertension, peripheral vascular disease, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated for Resident #57 revealed the resident had intact cognition. Resident #57 had a brief interview for mental status (BIMS) score of 15. The resident had no hallucinations, delusions, or rejection of care noted on the assessment. Resident #57 required limited assistance with all activities of daily living (ADLs) except eating (supervision) and toilet use (extensive assistance). The assessment noted that Resident #57 had no swallowing problems. The resident had a weight loss of greater than 10% in the last six months which was a physician prescribed weight loss program. Review of the plan of care for Resident #57 dated 06/15/22 revealed the resident had a nutritional problem related to the history of diabetes mellitus type two. Interventions included monitoring meal intakes, providing double meats with meals, and providing snacks per facility policy. Review of the medical record for Resident #57 revealed a weight on 03/07/22 of 254 pounds (lbs.) and a weight on 03/24/22 of 176 lbs. Review of the continuity of care (COC) for Resident #57 dated 01/11/22 revealed a weight at the hospital of 202 lbs. The COC for Resident #57 dated 03/24/22 revealed a weight of 176 lbs. The weight loss for Resident #57 was 12.8% in a 75-day period. Telephone interview on 07/13/22 at 3:06 P.M. with Registered Dietician (RD) #87 verified she was not aware of the big weight discrepancy for Resident #57 until April 2022. In fact, RD #87 stated she had not addressed the weight loss for the resident until 04/29/22, over a month after the facility documented a large weight loss for Resident #57. RD #87 added double portions to the resident meals because he wouldn't take supplements. No reweighs were ordered for the resident. When asked what she would typically do in the case of a large weight discrepancy, RD #87 stated she would reweigh the resident to confirm the accuracy of the weight. Review of the dietary progress notes dated 06/17/22 at 11:16 A.M. revealed the resident had a 31% weight loss in a six-month time frame according to facility weights. This occurred in mid-March from 254 lbs to 176 lbs due to leg adapters and boots removed. Review of the facility policy titled Resident Height and Weight dated 07/16/21, revealed the facility failed to implement their policy. A plus/minus of 5 pounds of weight in one week will result in: reweigh within 24 hours, validation with nurse for accurate weight, and notify IDT team/doctor/family, if indicated. 366389 Page 12 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, record review, policy review, and review of the facility assessment, the facility failed to have sufficient staffing to assist the residents with their meals. This affected four residents (#11, #26, #50 and #56) of the six residents dependent on staff for feeding and four residents (#12, #69, #41, and #69) of five residents who required supervision during the meal. The facility census was 76. Findings included: Observation on 07/13/22 at 7:46 A.M. revealed a dietary staff member delivered the breakfast trays to the floor and placed the food cart directly in front of the nurse's desk. Observation at the same time revealed Residents (#12, #50, #29 and #69) were seated around the nurse's desk. Observation of staffing revealed State Tested Nursing Assistant (STNA) #13 was assigned to the 600 hallway and STNA #52 was assigned to the 500 hallway. There was one nurse Licensed Practical Nurse (LPN) #55 who was assigned to cover the 500 and 600 halls. Continued observation of the halls on 07/13/22 at 7:53 A.M. revealed STNA #52 started to remove trays from the cart and placed breakfast trays in front of Residents #29, #50, #69, and then placed a tray for Resident #12 behind a partitioned wall in the kitchenette area across from the nurse's desk. Residents #29 and #69 immediately started eating while Residents (#50 and #12) sat around the nurse's desk as they watched the other residents eating. STNA #52 was observed to tell Residents #12 and #50 she would be back in a bit. Observation on 07/13/22 at 8:10 A.M. revealed STNA #52 delivered breakfast tray to Resident #26's room and placed tray on the bed side table and immediately exited room. Surveyor observed STNA #52 state, I will be back in a bit Observation at same time revealed STNA #13 delivered a tray to Resident #56's room and immediately exited room. Interview with the Licensed Practical Nurse (LPN) #15 on 07/12/22 at 8:15 A.M. verified Residents (#12 and #69) were eating at the nurse's station without direct staff supervision and verified they were ordered to be supervised by staff while eating due to aspiration risk. LPN #15 additionally stated she was the nurse for the 500 and 600 halls and had 24 residents to care for and she was busy doing diabetic checks, administering medications and was not able to assist with feeding or providing direct supervision to residents eating. LPN #15 additionally stated she had a total of five Residents (#50, #26, #72, #11 and #56) who were dependent on staff for feeding and four Residents (#69, #12, #65, and #41) who required direct supervision during meals. Observation revealed STNAs (#17 and #74) were in Resident #25's room with the door shut. LPN #15 asked STNAs why Residents (#12 and #69) were not being supervised and STNAs indicated they were providing personal care for Resident #25 who was going out to an appointment. LPN #15 verified Residents (#12 and #69) were not being supervised as they ate. Observations on 07/13/22 at 8:17 A.M. revealed Residents (#26, #72 and #56) had their breakfast trays in front of them in their rooms and no staff assisting with eating, and Resident #50 was still seated at the nurse's desk with her tray in front of her without being fed. Observations on 07/13/22 at 8:18 A.M. reveled STNA #52 entered Resident #72's room and started to feed the resident. Interview with STNA #52 at the same time indicated she always fed resident #72 366389 Page 13 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some first due to the family's request. STNA #52 indicated she had three dependent residents to feed and could only feed one at a time since they were all in different areas of the hall. STNA #52 stated she normally fed Resident #72, then Resident #26 then Resident #50 who was normally seated at the nurse's station. STNA #52 additionally stated she had two Residents (#69 and #41) who required supervision at meals due to choking/aspiration risk. STNA #52 stated she was the only STNA on the 600 hall and could not feed three residents, provide supervision for two and complete other resident tasks at the same time. STNA #52 stated this staffing schedule was a normal routine for the hallway. Interview with STNA #13 on 07/13/22 at 8:26 A.M. indicated she was the only STNA for the 600 hall and had two Residents (#11 and #56) who were dependent for being fed and two Residents (#65 and #12) who required supervision during meal due to choking / aspiration risk. STNA #13 also stated she normally fed Resident #56 in her room then fed Resident #11 at the nurse's desk. STNA #13 indicated Resident #11 preferred to eat at the nurse's desk. STNA #13 stated Resident #11 was normally out of bed and placed at the nurse's desk to eat, but she didn't have time to get the resident up and out of bed so she left Resident #11's tray in the tray cart until she could get her up and out of bed. STNA #13 stated she was not able to feed two dependent residents, supervise two residents eating as well as taking care of other resident tasks at the same time. STNA #13 verified the above and stated the staffing schedule was a normal routine for the halls. Observation on 07/13/22 at 8:27 A.M. revealed STNA #16 arrived at the nurse's desk, sat next to Resident #50 and started to feed her. Interview with STNA #16 at the same time indicated she was the whole house aide and was told she needed to feed a resident. STNA #16 stated she was not aware the resident needed to be fed. Observation on 07/13/22 at 8:32 A.M. revealed STNA #52 exited Resident #72's Interview at the same time with STNA #52 revealed she had completed feeding Resident #72 and was going to feed Resident #26. Observation at 8:33 A.M. revealed Resident #26's covered tray was still situated in front of resident on the bedside table as STNA #52 entered and started to feed Resident #26. Observation on 07/13/22 at 8:34 A.M. revealed Resident #56 breakfast tray was still sitting on her bedside table in front of resident. Observation on 07/13/22 at 8:37 A.M. revealed STNA #13 arrived at Resident #56's room to feed her. Interview with STNA #13 at the same time indicated she had to complete other tasks for residents before she could feed Resident #56. STNA #13 verified resident #56's tray had been sitting in front of her with no staff to feed resident and verified the above information. The STNA additionally stated that as soon as she completed feeding Residents #56, she would get Resident #11 out of bed and feed her. STNA #13 verified Resident #11 should have been out of bed but due to having only one staff member on the floor, she was not able to complete all her morning tasks. Interview on 07/13/22 at 8:55 A.M. with Unit Manager (UM) #92 indicated she was not aware resident's trays had been sitting in front of them and her expectations were for staff to feed all dependent residents in a timely manner. UM #92 indicated she was not aware the resident was still in bed and needed to be gotten up. The Unit Manager indicated Resident #11 preferred to be up in a Geri Chair and eating at the nurse's desk. Staff also verified there was only one staff member for each hall and verified there were five resident's dependent on staff for feeding and four residents who required supervision. UM #92 indicated for breakfast service, residents ate on their units and in their rooms, but for lunch service, residents had option of going to the dining room to eat. 366389 Page 14 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0725 Observation on 07/13/22 at 9:00 A.M. revealed UM #92 feeding Resident #11 in her room. Level of Harm - Minimal harm or potential for actual harm Review of the medical records for Residents #11, #26, #50, and #56 revealed that each resident had impaired cognition and required extensive assistance of one staff member with eating. Residents Affected - Some Review of the facility assessment for the facility dated 07/01/21 through 06/30/22 revealed the facility had ten residents who needed limited or extensive assistance with eating. 85 residents were listed as requiring supervision with meals. Review of the facility policy titled Resident Rights dated 05/30/19, revealed the residents would be treated with dignity and respect and facility would provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the resident. 366389 Page 15 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

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 medical record review, staff interview, policy review, review of the pharmacy records, the facility failed to ensure behavioral interventions were completed prior to administering as needed (PRN) behavior medications. This affected one resident (#41) out of six residents reviewed for unnecessary medications. The facility census was 76. Findings included: Review of the medical record for Resident #41 revealed an admission date of 05/24/22. Diagnosis included cerebral infarction, dysphagia, diabetes mellitus, dementia, weakness, colitis, syncope, and collapse. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognition, was one-person physical assist and required supervision for eating. Review of the plan of care for Resident #41 revealed resident had behavior problems related to anxiety and dementia and used medication to manage behaviors. Interventions included observe for side effects, utilize non-pharmacological interventions prior to administering medications, administer medications as ordered, communicate with resident regarding behaviors, and monitor behaviors, Review of the physician orders for Resident #41 dated 06/07/22 indicated resident was ordered to be monitored for behaviors such as calling out, grabbing at staff, sexually inappropriate, knocking things off tables/desks and staff were to apply Non-Pharmacological Interventions included a snack, a drink, a change in environment - quieter area and the television. Review of the physician orders dated 06/20/20 and discontinued 06/27/22 reviewed resident was ordered Lorazepam (anti-anxiety/psychotropic) 0.5 milligram (mg) every four hours as need for anxiety. Review of the physician orders dated 6/27/20 and discontinued on 06/30/22 revealed Resident #41 was ordered haloperidol (anti-psychotic) one mg every six hours as needed (PRN) for agitation. Review of the active physician orders dated 6/30/22 and scheduled to be discontinued on 07/30/22 revealed Resident #41 was ordered Haldol (anti-psychotic) one mg every six hours PRN for agitation. Review of the June 2022 medication administration record (MAR) for Resident #41 indicated the following: a. Resident #41 was administered Haldol one mg PRN at 06/28/22 at 6:01 P.M. June MAR indicated no Non-Pharmacological Interventions were recorded for PRN dosage of Haldol administered. b. Resident #41 was administered Haldol one mg PRN at 06/29/22 at 2:46 P.M. The June MAR indicated no Non-Pharmacological Interventions were recorded for the PRN dosage of Haldol administered. c. Resident #41 was administered Lorazepam 0.5 mg on 06/22/22 at 7:38 A.M., at 3:15 P.M. and at 8:17 P.M. The MAR indicated Non-Pharmacological Interventions were only recorded for one of the three PRN dosages of Lorazepam administered. 366389 Page 16 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few d. Resident #41 was administered Lorazepam 0.5 mg on 06/23/22 at 2:03 A.M., at 9:56 A.M. and 8:50 P.M. The MAR indicated Non-Pharmacological Interventions were only recorded for two of the three PRN dosages of Lorazepam administered. e. Resident #41 was administered Lorazepam 0.5 mg on 06/24/22 at 2:48 P.M. and 7:57 P.M. The MAR indicated no non-pharmacological interventions were recorded for the two PRN dosages of Lorazepam administered. f. Resident #41 was administered Lorazepam 0.5 mg on 06/25/22 at 1:15 P.M. and at 7:24 P.M. MAR indicated Non-Pharmacological Interventions were only recorded for one of the two PRN dosage of Lorazepam administered. g. Resident #41 was administered Lorazepam 0.5 mg on 06/26/22 at 6:22 A.M., at 11:38 A.M., at 435 P.M. and at 8:02 P.M. The MAR indicated Non-Pharmacological Interventions were only recorded for ONE of the four PRN dosages of Lorazepam administered. h. Resident #41 was administered Lorazepam 0.5 mg on 06/27/22 at 4:11 A.M. and 10:07 A.M. MAR indicated Non-Pharmacological Interventions were only recorded for one of the two PRN dosages of Lorazepam administered. Review of the July 2022 MAR medication administration record for resident #41 indicated the following: a. Resident #41 was administered Haldol one mg (PRN) on 07/01/22 at 12:11 A.M., 8:11 A.M. and 2:55 P.M. the MAR indicated Non-Pharmacological Interventions were only recorded for two of the three PRN dosages of Haldol administered. b. Resident #41 was administered Haldol one mg (PRN) On 07/04/22 at 12:08 A.M., 11:19 A.M. and 11:07 P.M. The MAR indicated Non-Pharmacological Interventions were only recorded for two of the three PRN dosages of Haldol administered. c. Resident #41 was administered Haldol one mg (PRN) on 07/07/22 at 5:15 P.M. The MAR indicated no Non-Pharmacological Interventions were only recorded for the PRN dose of Haldol being administered. d. Resident #41 was administered Haldol one mg (PRN) On 07/09/22 at 8:19 A.M. and 7:40 P.M. the MAR indicated Non-Pharmacological Interventions were only recorded for one of the two PRN dosages of Haldol administered. Interview with the Director of Nursing (DON) on 07/14/22 at 2:25 P.M., verified non-pharmacological interventions were not completed before resident was administered PRN doses of Lorazepam and Haldol. The DON stated the psychiatrist ordered the PRN Haldol for 30 days so he did not have to rewrite it in 14 days and so resident could have access for continuous 30 days. The DON verified PRN antipsychotic were to be limited to 14 days. Review of the facility policy titled medication Management dated 08/01/20 reveled the facility would consider non-pharmacological interventions before initiating a medication including an Antipsychotic. 366389 Page 17 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to label, date, and discard expired foods in the kitchen and in the resident refrigerators. This had the potential to affect 75 residents out of 75 residents who received food from the kitchen. The facility identified one resident (#15) who ate nothing by mouth. The facility census was 76. Findings include: Observation on 07/11/22 at 8:25 A.M. revealed the following sanitation condition: In the walk-in refrigerator there was a ham sealed in a bag dated 07/03/22. a pork loin with a pull date of 06/23/22 on a tray and a bag of boiled eggs dated 07/03/22. Interview on 07/11/22 at 8:25 A.M., the [NAME] # 82 was unsure if the food should be discarded within three or seven days after opening or preparation. [NAME] #82 verified the foods were past the use date of seven days and were unsafe to serve to the residents. Observation on 07/14/22 at 8:50 A.M. through 9:05 A.M. revealed the follow sanitation violations on 300/400, 500/600 and 100/200 resident unit refrigerators: On the Unit 300/400 unit, the resident food storage refrigerator had a sign stating foods in the resident refrigerator were to be labeled with the resident name and dated. There was no temperature log to indicate monitor of the refrigerator temperature, there was chicken broth with no date or name, an opened container of liquid coffee expiration date 06/29/22, with no name, and a protein sandwich dated 07/02/22. On the Unit 500/600 unit, the resident food storage refrigerator had a sign stating foods in the resident refrigerator were to be labeled with the resident name and dated. There was an open and unsealed cream cheese undated and unlabeled, a bowel of unidentifiable food unlabeled and undated, a large bag with no name of undated, unlabeled, foods in containers, and there was no temperature log to indicate monitor of the refrigerator temperature. On the 100/200 unit, the resident food storage refrigerator, there was a sign stating foods in the resident refrigerators were to be labeled with the resident name and dated. There was undated pizza boxes containing food, a meat sandwich dated 06/27/22, a container of unidentifiable food unlabeled and undated, a large bag with no name of various containers of undated and unlabeled foods, and there was no temperature log to indicate monitor of the refrigerator temperature. Interview on 07/14/22 at 9:05 A.M., with the Diet Aide #39 verified the foods in the resident unit refrigerators were undated and unlabeled, and the foods were not safe for residents to consume after seven days. She stated it was dietary staff responsibility to monitor and remove expired and undated foods from the resident refrigerators. She verified a completed temperature log should have been on each refrigerator. Interview on 07/14/22 at 10:20 A.M., with the Diet Manger #42 verified prepared foods should be discarded after seven days and all foods should be labeled and dated in the kitchen refrigerators and in the resident refrigerators. 366389 Page 18 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0812 Review of the facility policy titled Food Storage: Cold Food, dated September 2017 revealed all foods will stored wrapped, in covered containers and are labeled and dated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 366389 Page 19 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

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, staff and resident interview, policy review, review of the Centers for Medicare and Medicaid Services (CMS) memorandums, review of the centers for Disease Control (CDC) guidelines, the facility failed to ensure newly admitted unvaccinated residents were quarantined to prevent the spread of the Coronavirus (COVID-19). This directly affected Resident #73 but had the potential to affect all residents in the facility. In addition, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) to prevent the spread of COVID-19. This had the potential to affect all residents in the facility. The facility census was 76. Residents Affected - Many Findings included: 1. Review of the medical record for Resident #73 revealed an admission date of 02/23/22. Diagnosis included anxiety, congestive heart failure (CHF), asthma, acute kidney failure and muscle weakness. Diagnosis had no documentation for the resident having COVID-19 in last 90 days or being vaccinated against COVID-19 and review of the immunization records for Resident #73 revealed no documented evidence of a COVID-19 vaccination. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had moderately impaired cognition, required two persons limited and extensive assistance with activities of daily living (ADL). Review of Resident #73's census page on 07/11/22 reveled the census was last updated on 05/16/22 and Resident #73 was listed as being in the same room as Resident #128. Review of census page for Resident #128 revealed she was admitted to Resident #73's room on 07/09/22. 2. Review of the medical record for Resident #128 revealed an admission date of 07/09/22. Diagnoses included Parkinson's, congestive heart failure (CHF), atherosclerotic heart disease, cerebral infarction, seizures, and weakness. Review of the immunizations records for Resident #128 reveled no documented evidence the resident was vaccinated against COVID-19 Review of the admission assessment for Resident #128 dated 07/09/22 indicated resident was cognitively intact, required extensive and limited assistance and supervision with activities of daily living (ADL). Review of the hospital discharge notes for Resident #128 and continuity of care notes for Resident #128 dated 07/09/22 indicated resident had never received a COVID-19 vaccination. Review of the nurse progress notes for Resident #128 dated 07/09/22 at 2:08 P.M. revealed the resident was admitted to the facility. The progress notes had no documentation or any indication resident was placed in quarantine or transmission-based precautions (TBP) for being newly admitted . During random observation of the 200 hall on 07/11/22 at 3:38 P.M. revealed residents (#128 and #73) were being housed in the same room. Observation revealed no evidence Resident #128 was being quarantined on TBP for COVID-19. Interview with Resident #128 and Resident #128's family at same time indicated she had not been vaccinated against COVID-19 and was never placed in quarantined upon being admitted on [DATE]. 366389 Page 20 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview with Staff #98 on 07/11/22 at 4:30 P.M., verified Resident #128 was newly admitted on [DATE]. Interview with Staff #98 indicated she was not aware the resident had not been vaccinated against COVID-19 and should have placed in quarantined upon admission. Staff #98 indicated the resident tested negative for COVID-19 prior to release from hospital and upon admission to the facility. Staff #98 verified Resident #128 should have been quarantined due to not being vaccinated and verified Residents #128 and #73 were being housed in the same room. Staff #98 verified Resident #73 was admitted on [DATE] and had no record of being vaccinated against COVID -19. Interview with Infection Preventionist/Director of Nursing (DON) on 07/11/22 at 4:40 P.M. verified Resident #128 was newly admitted and should have been placed in quarantined due to not being vaccinated against COVID-19. Review of the nurse progress notes for Resident #128 dated 7/11/22 at 5:02 P.M. revealed the resident was moved from Resident #73's room and placed in private room and quarantined for being newly admitted and unvaccinated. 2. Observation of 600 hall on 07/12/22 at 3:53 PM revealed Resident #127's room had a TBP transmission-based PPE cart outside the door. Interview with Licensed Practical Nurse (LPN) #15 at same time verified resident was recently admitted on [DATE] and placed in quarantine status due to not being up to date with COVID-19 vaccinations. Continued observation of the room with LPN #15 revealed State Tested Nurse Aides (STNA) (#17 and #74) were in the residents rooms providing care to resident. STNAs (#17 and #74) indicated they had just completed toileting Resident #127 in the bathroom as they assisted her out of the bathroom. Further observation revealed STNAs (#17 and #74) had on surgical masks, no gowns, no gloves, and no face shield and/or eye protection. LPN #15 verified STNAs were in the room of a TBP resident and stated her expectations were for staff to don the appropriate PPE when entering a resident's rooms who was on quarantined status for COVID-19. Interviews with STNAs (#17 and #74) indicated they were not aware they had to wear additional PPE in the resident's room. Interview with Staff #92 on 07/12/22 at 3:56 P.M. indicated her expectations were for staff to be in full PPE upon entering the room of a resident who was on TBP and in quarantine for COVID-19. Observation of isolation equipment on 07/13/22 9:00 A.M. at with Staff #92 revealed enough PPE available for staff use with quarantine and COVID-19 positive residents. Staff #98 stated the facility had plenty of PPE to care for residents in quarantine and on isolation due to COVID-19. Review of the facility policy titled Criteria for COVID-19 requirements and Resident Placement, dated 03/24/22 revealed newly admitted unvaccinated or up to date resident would be quarantined in a private room for at least 10 days. Policy also indicated staff would wear appropriate PPE for quarantined or isolated residents. Review of the CDC website titled interim infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2029 (COVID-19) Pandemic https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html updated, 02/02/22, revealed Health Care Professionals (HCP) working in health care facilities areas are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. Guidelines revealed PPE for health care personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a (National Institute Occupational Safety and Health) (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. 366389 Page 21 of 22 366389 07/21/2022 Forest Hills Healthcare Center. 8700 Moran Road Cincinnati, OH 45244

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the CDC website titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated 02/02/22 indicated newly admitted residents to long term care who were not update to date with vaccinations, should be in TBP (quarantined) Residents Affected - Many Review of Centers for Medicare and Medicaid Services (CMS) memo titled COVID-19 Long-Term Care Facility Guidance., dated 03/10/22, revealed all nursing homes shall ensure they are complying with all CMS and CDC guidance related to infection control. 3. Observation on 07/12/22 at 12:50 P.M. of STNA #74 on the 300/400 hallway of the facility, revealed the aide was walking into a residents room without her mask over her face and no eye protection over her face. Continued observation on 07/12/22 at 12:52 P.M. of STNA #74 revealed she pulled her cloth mask down over her mouth and nose and was not wearing eye protection over her face. Interview on 07/12/22 at 12:55 P.M. with STNA #74 confirmed that she was not originally wearing a mask over her face, then pulled the mask down over her face. The STNA also confirmed she was wearing a cloth mask over her face with no eye protection. STNA #74 stated she was aware of the policy and had her eye glasses with her. 4. Review of the medical record for Resident #225 revealed admission date of 07/09/22 with a diagnosis of Parkinson Disease. Physician orders dated 07/11/22 included the resident should be in COVID-19 precautions for 10 days. Observation on 07/13/22 at 9:40 A.M., revealed Registered Nurse (RN) #77 donning gown, eye protection, gloves, and booties. RN #77 put on a surgical mask, then a N95 mask and then a second surgical mask over the N95 mask. RN #77 entered the room of Resident #225, performed care, doffed the gown, booties, and gloves. She removed the top surgical mask and the N95 mask, leaving the underlying surgical mask. She did not perform hand sanitizing or sanitize the eye protection shield. Interview on 07/13/22 at 9:45 A.M., RN #77 verified she should not have worn a surgical mask under the N95 and should have used hand sanitizer and sanitized the eye protection shield after doffing the personal protective equipment (PPE). 366389 Page 22 of 22