Health inspection·May 2, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #54 and Resident #55 were provided proper notice when cut from skilled nursing care and remained in the facility. This affected two residents (#54 and #55) of the three residents reviewed for liability notices. Residents Affected - Few Findings include: 1. Review of Resident #54's medical record revealed an admission date of 12/22/21 with diagnoses including abdominal aortic aneurysm, ruptured, pulmonary hypertension, cardiomegaly, and pleural effusion. Review of the physician's orders revealed the resident received skilled nursing services from 12/22/21 through 12/27/21. Further record review revealed the facility provided the resident a Notice of Medicare Non-Coverage (NOMNC) on 12/22/21 and there was no appeal for the decision to end the resident's services. The resident remained in the facility for long term care. Review of the medical record revealed the facility failed to provide the resident a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form as required to allow the resident to choose to continue the services when she did not discharge from the facility. On 04/27/22 at 3:22 P.M., interview with the Director of Nursing (DON verified the resident did not receive the correct SNFABN form at the time services were cut. 2. Review of Resident #55's medical record revealed an admission date of 10/22/21 with diagnoses including type 2 diabetes mellitus, diverticulosis of intestine, hyperlipidemia, wheezing, and difficulty in walking. Review of the physician's orders revealed the resident received skilled nursing services from 10/22/21 through 02/10/22. Further record review revealed the facility provided the resident a Notice of Medicare Non-Coverage (NOMNC) on 11/14/21 and there was no appeal for the decision to end the resident's services. The resident remained in the facility for long term care. Review of the medical record revealed the facility failed to provide the resident a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form as required to allow the resident to choose to continue the services when she did not discharge from the facility. Page 1 of 16 366413 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0582 Level of Harm - Minimal harm or potential for actual harm On 04/27/22 at 3:22 P.M., interview with the Director of Nursing (DON verified the resident did not receive the correct SNFABN form at the time services were cut. On 04/28/22 at 1:02 P.M. interview with the DON revealed the facility does not have a specific policy for ABN. Residents Affected - Few Review of the facility policy titled, NOMNC Completion SOP, dated 06/22/21 revealed in the Beneficiary requirement table from CMS (on pages 3 and 4), there were clear guidelines for when a NOMNC was issued for a Medicare recipient. The guidelines further revealed if a resident had a three day stay but required only custodial care, the facility should issue an SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) when services were cut/discontinued. 366413 Page 2 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #40, who had a diagnosis of bipolar disorder, had a Pre-admission Screening and Resident Review (PASARR) completed to reflect the mental health diagnosis to determine whether the resident qualified for Level II services. This affected one resident (#40) of one resident reviewed for PASARR. Findings include: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic respiratory failure with hypoxia, bipolar disorder, anxiety disorder, major depressive disorder and retention of urine. Review of the PASARR screening form revealed the resident had depression and personality disorder. The PASARR failed to reflect the resident's diagnosis of bipolar disorder Review of the progress notes, dated 04/12/22 revealed resident's son called into facility and spoke with resident's nurse and received an update on the resident's behaviors and was informed the resident was planning to discharge today to a local hospital behavioral unit for a period of time in an attempt to stabilize the resident's mood and assist with resident's medication refusals. Review of the discharge Minimum Data Set (MDS) 3.0 assessment, dated 04/13/22 revealed the resident had mild cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require extensive assist from staff for toileting, mobility and transfers. Review of the care plan, dated 04/25/22 revealed Resident #40 presented with a diagnosis of bipolar disorder and demonstrated mood swings, irritability and elevated mood. Interventions included medication per orders, observe mood, affect, and behaviors with all hands on care and contact and psychological services per orders/as needed. Review of physician's orders for Resident #40, dated 04/25/22 revealed an order for the medication, Lamictal 150 milligrams for bipolar affective disorder, Risperdone tablet 0.5 mg for bipolar effective disorder day and night and Trazodone 25 mg for anxiety and depression at bedtime. The resident received the medications as ordered. On 04/26/22 at 1:14 P.M. interview with the Director of Nursing verified the resident's PASARR form did not include the resident's diagnosis of bipolar disorder. Review of the facility undated policy titled PASARR Quick Sheet revealed if an individual had a severe mental illness/behavioral health (BH) diagnosis (example schizophrenia, bipolar disorder, major depression disorder and anxiety disorder) complete a significant change form (MAP 4095) and contact PASARR office. 366413 Page 3 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

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 observation, record review, facility policy and procedure review and interview the facility failed to develop a respiratory care plan for Resident #41 who had respiratory diagnoses and the use of supplemental oxygen. The facility also failed to ensure fall prevention interventions were implemented as per the resident's plan of care. This affected one resident (#41) of 15 residents reviewed for care plans. Findings include: A review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonitis due to the inhalation of food and emesis, acute and chronic respiratory failure with hypoxia, congestive heart failure, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, dementia, difficulty walking, unsteadiness on his feet, muscle weakness, dizziness and giddiness, macular degeneration, overactive bladder, anxiety and insomnia. a. A review of Resident #41's physician's orders revealed the resident had an order in place to receive oxygen at two liters per minute (LPM) per nasal cannula on a continuous basis. The resident also had an order for the use of Albuterol Sulfate 0.083%/ 0.5 milliliters (ml) per inhalation via a nebulizer twice a day for the diagnoses of wheezing and shortness of breath. The order for the Albuterol Sulfate had been in place since 03/01/22 and the order for the supplemental oxygen was initiated on 04/23/22. A review of Resident #41's active care plans revealed the resident did not have a care plan in place to address his respiratory diagnoses, use of oxygen or his use of Albuterol Sulfate twice a day per inhalation via a nebulizer. On 04/26/22 at 9:37 A.M. an observation of Resident #41 noted him to be lying in his bed with his eyes closed. The resident was noted to have an oxygen concentrator in his room as well as a nebulizer machine. He was not wearing the oxygen at the time of the observation. On 04/27/22 at 10:35 A.M. an interview with the Director of Nursing (DON) confirmed Resident #41 did not have a care plan in place to address his use of supplemental oxygen or nebulizer treatments. She agreed the resident should have had a care plan in place for his respiratory diagnoses and respiratory treatments received. b. A review of Resident #41's physician's orders revealed the resident was supposed to have a non-slip material to his recliner at all times. The order originated on 01/13/22. The resident also had an order for the use of non-slip material to his wheelchair as the resident would allow (order originated on 03/14/22). A review of Resident #41's care plans revealed the resident was at risk for falling related to recent falls and decreased mobility. The goal was to remain free of falls with major injury. The interventions on the care plan included the use of non-slip material to his wheelchair and recliner. A review of Resident #41's progress notes revealed a fall occurred on 01/10/22 at 10:56 P.M. when the resident was noted in front of his recliner. A new intervention was added for the use of Dycem (non-slip) material to the recliner. 366413 Page 4 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A progress note dated 03/12/22 at 6:45 P.M. revealed Resident #41 was observed lying on his back next to his bed. The resident stated he was trying to get into bed from his wheelchair and slid out of his wheelchair onto the floor. A new intervention was added to keep a Dycem pad to his wheelchair seat. On 04/27/22 at 8:55 A.M. an observation of Resident #41 was done with Registered Nurse (RN) #314 to ensure fall prevention interventions were in place. At the time of the observation, Resident #41's recliner chair and wheelchair were checked with no evidence of a non-slip material being present in either chair. RN #314 searched the resident's room and was not able to find any evidence of the non-slip material being in his room. The RN confirmed the resident should have the non-slip material in his recliner at all times and in his wheelchair that was positioned next to his bed. She also confirmed the use of the non-slip material in his recliner and wheelchair were fall prevention interventions implemented following previous falls. A review of the facility Fall Management Program Guidelines, revised 05/31/17 revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The fall risk assessment was included as part of the admission and Quarterly Nursing Observation and other events/ observations in the electronic health record. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors. 366413 Page 5 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #41, who was dependent on staff for personal care received timely and adequate assistance to keep his fingernails clean and trimmed. This affected one resident (#41) of one resident reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings include: A review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, adult onset diabetes mellitus and macular degeneration. A review of Resident #41's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. No behaviors or rejection of care was noted to have occurred during the seven day assessment period. The assessment revealed the resident required an extensive assist of two staff for transfers and personal hygiene and was totally dependent on two staff for bathing. A review of Resident #41's care plans revealed he required staff assistance to complete activities of daily living (ADL's) tasks completely and safely. The goal was for the resident to have ADL needs met safely by staff. The interventions included observing for deterioration in ADL abilities and report if occurs and allow resident sufficient time to complete all or part of task. There was nothing on the care plan about assisting the resident with cleaning and trimming his fingernails. On 04/26/22 at 9:32 A.M. an observation of Resident #41 revealed he had long fingernails with a black colored substance under the end of the nails. Subsequent observations on 04/27/22 at 2:30 P.M. revealed the resident's fingernails remained long and dirty. Findings were verified by Registered Nurse (RN) #314. On 04/27/22 at 8:55 A.M. an interview with RN #314 verified Resident #41's fingernails were long and had a black substance under the end of some of his fingernails. She confirmed the staff should be cleaning and trimming the resident's fingernails as needed. RN #314 informed the resident that she would come back and trim his fingernails. The resident responded I wish you would. 366413 Page 6 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

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 observation, record review, facility policy and procedure review and interview the facility failed to ensure fall prevention interventions were in place for Resident #41 who was at risk for and had a history of falls. This affected one resident (#41) of three residents reviewed for falls. Findings include: A review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, difficulty walking, unsteadiness on his feet, muscle weakness, dizziness and giddiness, macular degeneration, overactive bladder, anxiety and insomnia. A review of Resident #41's physician's orders revealed the resident was to have a non-slip material to his recliner at all times. The order originated on 01/13/22. The orders also included the use of non-slip material to his wheelchair as the resident would allow (order originated on 03/14/22). A review of Resident #41's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. No behaviors or rejection of care were noted during the seven days of the assessment period. The resident required an extensive assist of two staff for transfers and toilet use and required an extensive assist of one staff for ambulation in his room and locomotion on and off the unit. Balance issues were noted with all types of transfers requiring staff assistance to stabilize. A walker and wheelchair were mobility devices used. The MDS assessment noted the resident had two falls without injury since his prior assessment. A review of Resident #41's care plans revealed the resident was at risk for falling related to recent falls and decreased mobility. The goal was to remain free of falls with major injury. The interventions on the care plan included the use of non-slip material to his wheelchair and recliner. A review of Resident #41's progress notes revealed a fall occurred on 01/10/22 at 10:56 P.M. when the resident was noted in front of his recliner. A new intervention was added for the use of Dycem (non-slip) material to the recliner. A progress note dated 03/12/22 at 6:45 P.M. revealed Resident #41 was observed lying on his back next to his bed. The resident stated he was trying to get into bed from his wheelchair and slid out of his wheelchair onto the floor. A new intervention was added to keep a Dycem pad to his wheelchair seat. On 04/27/22 at 8:55 A.M. an observation of Resident #41 with Registered Nurse (RN) #314 was completed to ensure fall prevention interventions were in place. Resident #41's recliner chair and wheelchair were checked with no evidence of a non-slip material being present in either chair. RN #314 searched the resident's room and was not able to find any evidence of the non-slip material being in his room. RN #314 confirmed the resident should have the non-slip material in his recliner at all times and in his wheelchair that was positioned next to his bed. She also confirmed the use of the non-slip material in his recliner and wheelchair were fall prevention interventions implemented following previous falls. 366413 Page 7 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility Fall Management Program Guidelines, revised 05/31/17 revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The fall risk assessment was included as part of the admission and Quarterly Nursing Observation and other events/ observations in the electronic health record. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors. 366413 Page 8 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, congestive heart failure, Alzheimer's disease, dementia and anxiety. Residents Affected - Few A review of Resident #41's physician's orders revealed the resident was to receive oxygen at two liters per minute (LPN) per nasal cannula on a continuous basis. The resident also had an order to receive Albuterol Sulfate 0.083% (0.5 milliliters) per inhalation via a nebulizer twice a day. A review of Resident #41's care plans revealed the resident did not have a respiratory care plan in place to address his respiratory diagnoses or the use of oxygen and nebulizer treatments. The resident did have a care plan for being at risk for complications related to sleep apnea but it did not identify him as wearing oxygen as part of his interventions. On 04/26/22 at 9:37 A.M. an observation of Resident #41 revealed he had an oxygen concentrator in his room that was not in use. There was a nasal cannula attached to the concentrator that was lying across the top of the concentrator. The oxygen tubing was not properly stored while not in use nor was it dated to show when it was last changed. The resident had a nebulizer machine sitting on the top of his night stand that had the mask lying on top of it and was also not stored properly or dated. Subsequent observations on 04/27/22 at 8:51 A.M. revealed the oxygen tubing and nebulizer mask to remain stored in the same manner as previously observed without being stored inside a plastic bag or with a date to show when it was last changed. Findings were verified by Registered Nurse (RN) #314. On 04/27/22 at 8:51 A.M. an interview with RN #314 confirmed Resident #41's oxygen was not on as ordered by the physician. She acknowledged the physician's orders were for the resident to wear the oxygen on a continuous basis. RN #314 also confirmed the oxygen tubing and the nebulizer equipment was not dated or stored properly while not in use. A review of the facility policy on Administration of Oxygen, revised May 2018 revealed the staff were to date the tubing for the date it was initiated. Tubing should be changed monthly and as needed. Based on observation, record review, facility policy and procedure review and interview the the facility failed to ensure Resident #204 had tracheostomy orders for care and respiratory equipment (oxygen, trach and suction) available in the resident's room and failed to ensure respiratory equipment (oxygen and nebulizer) were dated and stored properly for Resident #41 when not in use. This affected two residents (#41 and #204) of two residents reviewed for respiratory care. Findings include: 1. Record review revealed Resident #204 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, tracheostomy, and sleep apnea. Review of Resident #204's hospital records (prior to admission) revealed the resident had a tracheostomy placed in 2005 after complications from a carotid endarterectomy. The resident leaves the tracheostomy tube capped in the daytime and unplugs her tracheotomy tube at night. The resident had #5 [NAME] tracheostomy tube replaced and was to return to the hospital in three months for continued 366413 Page 9 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0695 tracheostomy care. Level of Harm - Minimal harm or potential for actual harm Review of Resident #204's admission observation note, dated 04/19/22 revealed the resident had a capped trach and indicated to refer physician's orders for trach size and type. Residents Affected - Few Review of Resident #204's 48-hour plan of care for respiratory treatment revealed the resident had a trach and interventions included oxygen per orders and to follow protocols for care of trach and trach site. Review of Resident #204's orders, dated 04/19/22 to 04/26/22 revealed no evidence of any physician's orders for tracheostomy care, type or size of trach, suction or oxygen. Review of the completed facility CMS Matrix Form, dated 04/25/22 revealed no evidence the facility identified Resident #204 as having a tracheostomy. The box for tracheostomy was blank for the resident. On 04/26/22 at 11:43 A.M. Resident #204 was observed to have a tracheostomy. The tracheostomy dressing was undated and appeared to be discolored (off white) and gathered up under the trach. On 04/26/22 at 2:21 P.M. observation, interview and review of the resident's orders with the Director of Nursing (DON) revealed the resident did not have any physician's orders for the trach size/style, care, oxygen or suction. The resident did not have a suction machine in the room or extra supplies including an extra trach or oxygen in her room. The resident reported she had changed the trach dressing herself about two days ago after obtaining the supplies to change the dressing from the facility staff. The resident reported she would change the trach dressing at home herself and every six weeks she would go the doctor's office to have the trach replaced. The resident indicated she had the trach since 2006. On 04/26/22 at 3:34 P.M. interview with the DON revealed the facility had obtained the resident's hospital records to find out which style and size trach the resident had and was waiting on a courier to deliver the supplies. Review of the facility policy titled Tracheostomy Care, dated 12/01/21 revealed to provide tracheostomy care to maintain patency of the tracheostomy tube and reduce the risk of infection. Care would be provided as needed or as ordered. 366413 Page 10 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure verbal/written communication was maintained for Resident #202 with the hemodialysis center to ensure continuity of resident care. This affected one resident (#202) of one resident reviewed for hemodialysis. Residents Affected - Few Findings include: Record review revealed Resident #202 was admitted to the facility on [DATE] with diagnoses including stage three chronic kidney disease. On 04/26/22 at 2:41 P.M. interview with Resident #202, the resident's niece and the Director of Nursing (DON) revealed the resident just started hemodialysis last Monday and had dialysis treatments three times a week. The resident reported she was confused about her fluid restriction due to the dialysis center doctor telling her to only drink three small glasses of fluids, but today she had to go to the emergency room (ER) because she had an episode of hypotension (low blood pressure) and the doctor in the ER told her to drink more fluids. The resident revealed she had a dialysis treatment tomorrow and she planned to ask the doctor what she needed to do regarding her fluid intakes. Further review of Resident #202's medical record documentation revealed no evidence of any verbal or written communication notes from the hemodialysis center to the facility following the resident's treatments. Communication forms, dated 04/18/22, 04/20/22, 04/22/22 and 04/25/22 revealed the section for the dialysis center to complete was blank. The dialysis center section included the resident pre and post weight, labs drawn, concerns with dialysis, nutrition and fluids consumed, medication received, medication changes, diet/fluid order, new orders and dialysis vital signs. Review of Resident #202's nursing progress note, dated 04/26/22 revealed the resident was sent to the emergency room from an outside appointment because she had low blood pressure. Review of Resident #202's plan of care, dated 04/25/22 revealed the resident attended dialysis Monday, Wednesday and Friday. On 04/26/22 at 3:04 P.M. interview with the DON confirmed there was no evidence of communication notes from the dialysis center, and she would have to call the dialysis center and have them fax over the notes and she would call and clarify fluid restriction orders due to the resident currently did not have any orders for fluid restrictions. Review of the facility policy titled Guidelines for Dialysis, dated 12/02/21 revealed a report (may be written or verbal) shall be requested from the dialysis provider that would alert the campus regarding the resident's vital signs, tolerance to procedure, medication administered and other information deemed necessary for the ongoing provision of care. Upon return from the dialysis center the facility shall continue ongoing monitoring and review the dialysis providers paperwork for any necessary follow up requirements. 366413 Page 11 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, review of facility spread sheets, facility policy and procedure review and interview the facility failed to ensure residents were served proper serving sizes as per the spread sheet during the breakfast meal on 04/27/22. This had the potential to affect all 49 residents residing in the facility. Findings include: On 04/27/22 at 7:01 A.M. observation of breakfast meal tray line and review of the spread sheets with [NAME] #312 and Dietary Manager (DM) #346 revealed the breakfast menu was changed because the menu items were not available through the distributor. The menu was changed to toast, bacon/sausage and scrambled eggs. Further observation of the purred sausage revealed there was a #24 (1 1/3 ounces) scoop and the spread sheet called for a #30 (one ounces) scoop. However the DM reported residents should receive two ounces and she did not have another #16 scoop and instructed [NAME] #312 to give two #30 scoops. The pureed eggs had a #12 (2 2/3 ounce) scoop and the spread sheet called for a #16 (two ounce) scoop. The scrambled eggs had a #12 (2 2/3 ounce) scoop and should have had a #16 (two ounce) scoop and the mechanical sausage had #24 (1 1/3 ounce) scoop and the spread sheet called for a #16 (two ounce) scoop. Findings confirmed with the DM and cook during the observation. On 04/27/22 at 9:39 A.M. interview with DM #346 verified she was incorrect and residents receiving the pureed sausage should have only received one #30 scoop and residents who received the mechanical sausage would have not received enough as the cook had a #24 (1 1/3 ounce) scoop and the spread sheet called for a #16 (two ounce) scoop. The other items the scoop sizes were over the recommended amount per the spread sheet. The DM reported she had started all staff education on pulling the spread sheet for each meal to ensure adequate serving sizes to ensure adequate nutrition. Review of the facility undated portion control policy revealed dining service staff would portion to individuals based on planned menus that list the portion size for each food. Proper serving utensils would be used to assure accurate portions were served. If an individual requested small or double, portions, the request should be ordered by the physician, documented in the medical record, sent to dining services as a diet order and documented on the resident's tray card. 366413 Page 12 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility infection control logs, facility policy and procedure review and interview the facility failed to implement an effective antibiotic stewardship program to ensure antibiotics were not used unless residents met the criteria to treat an infection. This affected four residents (#33, #41, #46 and #47) of four sampled residents, ten additional residents (#8, #16, #27, #30, #44, #45, #51, #52, #53 and #201) identified on facility infection control logs to receive antibiotics without evidence of meeting any type of criteria for antibiotic use and had the potential to affect all 49 residents residing in the facility. Residents Affected - Many Findings include: 1. A review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] from home. Resident #33 had diagnoses including urinary tract infection (UTI) and dementia with behavioral disturbances. A review of Resident #33's medication administration history revealed the resident had an order to receive the antibiotic, Macrobid 100 milligrams (mg) twice a day for treatment of a UTI. She received the antibiotic from 03/14/22 and 03/17/22. A review of Resident #33's urinalysis (U/A) that was collected on 03/08/22, prior to her admission, revealed the U/A showed no growth of any organisms that could cause a UTI in the preliminary report. The final culture report showed mixed skin flora and no organisms present to show she had a UTI in which an antibiotic would be needed to treat an infection. A review of Resident #33's progress notes revealed an interdisciplinary team (IDT) note, dated 03/17/22 at 3:36 P.M. that revealed the resident was noted with antibiotic therapy on admission for a UTI. Urine culture was indicated to have been collected on 03/08/22 with no growth, mixed skin flora present. The resident previously had new urinary incontinence and urinary frequency. She was negative for McGeer criteria. On 04/28/22 at 1:15 P.M. findings were verified by the Director of Nursing (DON). The DON acknowledged Resident #33 was admitted to the facility with orders to receive the antibiotic, Macrobid for the treatment of a UTI. However, the U/A that was collected on 03/08/22 only showed mixed skin flora on the culture report. The DON acknowledged the antibiotic should have been discontinued upon admission as the resident's U/A results did not support she had a UTI that needed to be treated with an antibiotic. The DON initially reported the prior DON indicated the resident was admitted on a Thursday and her medications were not reviewed by her until the following Monday when the antibiotic treatment had already been completed. It was later determined the resident was admitted to the facility on a Monday and not a Thursday as reported by the prior DON. The prior DON then explained they were dealing with COVID-19 in the building at the time of the resident's admission, which was why she did not get to review the resident's medications upon her admission. She acknowledged the nurse (who admitted the resident) should have had access to her U/A results, at the time of the resident's admission, and notice she was being treated with an antibiotic for an infection she did not have. A review of the facility policy on Antibiotic Stewardship, effective 11/10/17 revealed the purpose of the policy was to optimize the treatment of infections by ensuring residents who required an antibiotic, were prescribed the appropriate antibiotic. The purpose also was to reduce the risk of 366413 Page 13 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many adverse events, including the development of antibiotic resistant organisms, from unnecessary or inappropriate antibiotic use. It was also to encompass a facility-wide system to monitor the use of antibiotics. Procedures included reviewing infections and monitor antibiotic usage patterns. New orders for antibiotic usage would be reviewed during the facility's Clinical Care Meetings on regular business days. They were to obtain and review laboratory reports for facility trends of resistance. They were to report on the number of antibiotics prescribed, per physician, and the number of residents treated each month. They were to include a separate report for the number of residents on antibiotics that did not meet criteria (McGeer Criteria) for active infection. 2. A review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including recurrent UTI's, Alzheimer's disease and dementia. A review of Resident #41's physician's orders revealed the resident was receiving the antibiotic, Macrodantin 50 mg by mouth every night at bedtime for three months. He also had an order to receive Levofloxacin (Levaquin) 500 mg by mouth once daily from 04/23/22 to 04/30/22. A review of Resident #41's progress notes revealed a nurse's note, dated 04/22/22 that indicated the resident's spouse had requested a urine sample be collected and sent to the lab. She did not want the resident straight catheterized (insertion of an indwelling urinary catheter to collect a urine sample). The staff was not able to get the resident to void in a hat to obtain a clean catch specimen as he had been incontinent all shift and was not able to inform the staff when he needed to void. A nurse's note dated 04/23/22 revealed the urine specimen had been obtained and the nurse practitioner from palliative care was notified of the resident's preliminary urine results. A new order was received to give the resident the antibiotic, Levaquin 500 mg by mouth daily for seven days. A review of a progress note dated 04/25/22 at 4:06 P.M. revealed the resident denied having any urinary symptoms. A review of Resident #41's U/A that was collected on 04/22/22 at 2:00 P.M. revealed a culture was also completed. The results of the final culture were received on 04/24/22 at 10:08 A.M. and showed mixed skin and fecal flora. There were no organisms identified to provide any evidence of the resident having an active UTI. A review of the facility infection control log for April 2022 revealed Resident #41 was identified as having received Levaquin 500 mg twice daily with a start date of 04/23/22 and an end date of 04/30/22. The culture date was on 04/22/22 and the diagnosis/ organism identified included mixed skin flora. The infection control log indicated the resident did not meet the McGeer's Criteria for the treatment of a UTI. On 04/27/22 at 1:48 P.M., an interview with the DON confirmed Resident #41 received an antibiotic (Levaquin) for the treatment of a UTI despite the U/A not supporting he had an active infection/UTI. The DON confirmed the urine culture results showed mixed skin flora and fecal flora indicating the sample was contaminated. There were no organisms identified that warranted the resident being treated for a UTI with an antibiotic. She acknowledged the resident was already receiving one antibiotic (Macrodantin) for prophylaxis for recurrent UTI's. The DON verified an additional antibiotic should not have been started until the U/A results confirmed he had a UTI or at least discontinued when it was determined through lab testing that he did not have one. 3. Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses 366413 Page 14 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many including retention of urine, urinary incontinence/overactive bladder, dementia, diabetes and cognitive communication deficit. Review of Resident #46's pharmacy recommendation, dated 11/27/21 revealed the pharmacist recommended discontinuing Oxybutynin 10 milligrams (mg) for incontinence or overactive bladder due to the medication was not recommended for residents over [AGE] years old. The physician agreed to discontinue medication. Review of Resident #46's orders and medication administration records dated 02/12/22 to 02/18/22 revealed Resident #46's was ordered and received the antibiotic, Macrobid 100 milligrams (mg) twice daily for urinary tract infection (UTI). Review of Resident #46's urinalysis results dated 02/09/22 and 02/12/22 revealed the physician had written a note to await culture results on 02/10/22. The culture was rejected, and a new urinalysis was collected on 02/12/22 which indicated the urine was negative and no culture was indicated. There was a note, dated 02/12/22 to continue Macrobid, however the Macrobid was not started until 02/12/22. Review of Resident #46's McGeer Criteria form, dated 02/09/22 and reviewed on 02/17/22 revealed the resident did not meet criteria for antibiotic treatment. An additional note indicated treatment was necessary as the resident had new urinary incontinence. The urinalysis was negative, and no culture was indicated. Review of Resident #46's bladder documentation dated 02/01/22 to 02/28/22 revealed the resident had ten episodes of urinary incontinence from 02/01/22 to 02/11/22 (prior to treatment) eight episodes of urinary incontinence from 02/12/22 to 02/18/22 (during treatment), and fifteen episodes of urinary incontinence from 02/19/22 to 02/28/22 (after treatment). Review of Resident #46's Minimum Data Set (MDS) 3.0 assessments, dated 11/16/21, 02/14/22 and 03/22/22 revealed on 11/16/21 the resident had no cognition impairment (Brief Interview for Mental Status (BIMS) score of 14) and was occasionally incontinent of urine. On 02/14/21 the resident now had cognitive impairment (BIMS of 9) and frequent urinary incontinence and on 03/22/22 the MDS reflected the resident had a BIMS score of 9 and occasional incontinence of urine. On 04/28/22 at 1:53 P.M. interview with the Director of Nursing (DON) verified Resident #46 did not meet criteria for antibiotic treatment, the resident had urinary incontinence prior to and continued to have urinary incontinence after the antibiotic treatment, even though the rational for antibiotic treatment was new urinary incontinence. 4. Record review for Resident #47 revealed the resident was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon, squamous cell carcinoma of anal skin, moderate protein-calorie malnutrition, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/05/22 revealed the resident had no impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score 15. This resident was assessed to require extensive one to two person assist with toileting, transfers and mobility. Review of laboratory urinalysis testing results, dated 04/12/22 revealed the resident was negative 366413 Page 15 of 16 366413 05/02/2022 Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701

F 0881 for a UTI. Level of Harm - Minimal harm or potential for actual harm Review of the nurse's progress notes, dated 04/14/22 revealed the physician was notified of a urine culture with new orders received to start the antibiotic, Levofloxacin 500 mg twice a day for seven days for UTI. Residents Affected - Many Review of the progress notes, dated 04/14/22 revealed the resident was noted to have hematuria (blood) in the catheter. A urinalysis showed positive pseudomonas; less than 100,000. New orders for Levaquin 500 mg for seven days. The progress note revealed negative for McGeer. Review of medication administration record revealed the resident received Levofloxacin 500 mg from 04/14/22 through 04/16/22. Review of the care plan, dated 04/18/22 revealed the resident had an indwelling Foley (urinary) catheter for wound healing, presence of Stage IV pressure injury to coccyx with incontinence and at risk for urinary tract infection (UTI). On 04/28/22 between 12:24 P.M. and 1:55 P.M. interview with Director of Health Services (DHS) #322 verified the physician acknowledged the resident did not meet the McGeer criteria for treatment of an infection/UTI, but ordered an antibiotic to be administered to the resident. 5. Further review of the facility infection control logs from February 2022 through April 2022 revealed Resident #8, #16, #27, #30, #44, #45, #51, #52, #53 and #201 had received antibiotics during this time period without evidence of meeting McGeer criteria. On 04/28/22 between 12:24 P.M. and 1:55 P.M. interview with Director of Health Services (DHS) #322 confirmed the physician ordered antibiotics for the residents identified above even though the residents had no evidence of meeting the McGeer criteria for infections. 366413 Page 16 of 16