Health inspection·June 8, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital record review, interview and policy review the facility failed to ensure timely physician notification related to mouth pain/thrush, lethargy and decreased meal and fluid intakes. This affected one resident (Resident #67) of three resident reviewed for change in condition. The census was 66. Findings include: Review of Resident #67's hospital records (prior to facility admission) dated 04/19/23 to 04/24/23 revealed the resident had a history of severe protein calorie malnutrition and had acute on chronic renal failure related to poor intake. Review of the hospital discharge summary plan dated, 04/24/23 revealed the resident had an echocardiogram (a scan used to look at the heart and near-by blood vessels) during her hospitalization that showed a grade one diastolic dysfunction (heart cannot fully fill during the diastolic part of the heartbeat). The resident's discharge orders revealed the resident required a cardiac 1500 milliliter (ml) fluid restriction daily (used to avoid overloading your heart if you have heart failure as more fluid in your bloodstream makes it harder for your heart to pump) and a minced moisture texture diet. Hospital discharge documentation noted the resident's stay was expected to be less 30-days at the skilled nursing facility. Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Record review revealed an admission order, dated 04/24/23 for a no added salt (NAS) mechanical soft diet. On 04/25/23 the resident's diet was upgraded to a regular texture diet; however this was not communicated to the dietary department and the resident never received the upgraded diet while in the facility. Review of Resident #67's fluid restriction worksheet and physician's orders, dated 04/25/23 revealed the resident was not to exceed a total daily fluid intake of 1500 milliliters (ml); 720 ml dietary and 780 ml nursing. The worksheet noted one cup of 240 ml of fluids on each meal tray. Record review revealed a plan of care, dated 04/26/23 related to altered health maintenance due to progress physical and mental status. Interventions included to monitor for signs and symptoms of cardiac distress and report to the cardiac and vascular doctor if any weight gain/loss, edema, fatigue, Page 1 of 22 366478 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few chest pain, confusion, nausea, decreased urinary output, or increased laboratory testing (BUN/Creatine). Interventions also included to provide diet ordered; if less than 50% consumed offer supplements as ordered (the resident had no orders for nutritional supplements at this time). Stress the importance of good nutrition and how it promotes healing and increases resistance. Review of Resident #67's speech notes authored by Speech and Language Pathologist (SLP) #201 dated 04/26/23 revealed the resident ate slightly better after speech sat and ate their own individual items while the resident ate. The resident reported the food was bland, Mrs. Dash was used and the resident reported the food was better. Review of Resident #67's nutrition risk tool, dated 04/27/23 and authored by Registered Dietician (RD) #198 revealed the resident was at moderate risk for nutritional decline due to having a moderate decrease in food intake, no weight loss in three months, able to get out of bed/chair but does not go out, BMI 21 to less than 23, had suffered psychological stress or acute disease in the past three months, and no psychological problems. There were no guidelines to direct staff on how to proceed with a resident assessed with nutritional risks. Review of Resident #67's dietary assessment, dated 04/27/23 and authored by RD #198 revealed the resident was hospitalized for an intertrochanter fracture and had undergone surgery (gamma nailing) on 04/20/23 (during the resident's hospitalization). The resident lived at home (prior to the hospitalization), and family had provided her with breakfast and dinner. The resident reported she would often forget to eat lunch due to being home alone. The resident reported she had recently started drinking Boost (a nutritional supplement) once daily due to weight loss and lack of intake. The assessment noted, a no added salt (NAS) with thin liquids and regular textured solids diet. Documentation indicated the resident was consuming 25-50% of meal trays. The dietary note indicated the RD would order a house supplement, 120 milliliters (ml) twice daily to provide an additional 240 calories and 20 grams of protein. The dietary assessment also reflected the resident had a deep tissue injury (pressure ulcer) to the coccyx per a skin grid assessment completed on 04/25/23. Resident #67 was noted to be at risk for decline in nutritional status per the Nutrition Risk Tool with a score of 9 (moderate risk for nutritional decline). The resident had nutritional diagnoses including malnutrition, chronic illness, severe muscle/fat loss, weight loss, and suboptimal intakes. Nutritional interventions included to discuss the importance of adequate nutrition to help aid in wound healing, encourage adequate calories, protein, nutrition supplements, and micronutrients to help in wound healing, encourage oral intake with at least 50% consumption at mealtimes, encourage snacking frequently between meals, and encourage compliance with fluid restrictions. Nutrition monitoring and evaluation included monitoring weights via weight report (paper weight book), monitor intakes, and skin integrity. The nutrition goals included the resident would consume at least 50% of meals, snack once daily, and consume Prostat (supplement) 30 ml daily with 100% consumption and house supplement 120 ml twice daily with 100% consumption. Review of Resident #67's paper medical record and electronic medical record (EMR) revealed no evidence a house supplement was ordered or administered to Resident #67 during the residents stay. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/23 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status of three out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use, extensive assistance from one staff for dressing, supervision from staff for eating, and limited assistance from one staff for personal hygiene. The resident had no impairment to the upper or lower body and used a walker. The MDS assessment revealed the resident was at 366478 Page 2 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few risk for pressure ulcer development and had one unstageable deep tissue injury on admission located on the coccyx. On 05/04/23 a speech note authored by Speech Therapist (SLP) #201 indicated the resident remarked that it hurt to eat. Speech therapy noted something that appeared ulcer-like and hurt whenever even light pressure was applied (to the resident's mouth). The note indicated the nurse was made aware and was going to have the physician look at it first before making a referral to the dentist. On 05/05/23 a speech note authored by SLP #201 indicated the resident was still complaining of her mouth hurting when eating. The note indicated nursing was aware and would have the physician look at it when he comes in. Review of Resident #67's therapy note dated 05/08/23 and authored by SLP #201, revealed ST #201 called Resident #67's family (Family Member #199) regarding the resident's diet order. Resident #67's diet was a regular diet, however the diet slip on the meal tray had not been updated. The diet slip was now updated, and the family was notified the resident would receive the correct diet. On 05/09/23 a speech note authored by SLP #201 indicated the resident had complaints of mouth pain when eating. Nursing and physician aware. The speech note did not indicate who notified the physician. Review of Resident #67's (nursing) progress notes dated 04/25/23 to 05/09/23 revealed no documented assessment or evidence of the resident's reported complaints of mouth pain. Review of a progress note dated 05/10/23 at 11:10 P.M. and authored by ADON #120 revealed the Resident #67 was complaining of sores in (her) mouth and mouth pain. The resident was noted to have inflamed gums and few white patches/sores noted. The physician was notified and ordered Clotrimazole (antifungal) lozenges for 14 days due to thrush (yeast infection in the mouth). Review of Resident #67's physician progress notes revealed no evidence the resident was assessed/seen by a physician and/or other designated healthcare provider on behalf of the physician during the resident's stay, with the exception of 04/25/23 when a history and physical was completed. Review of Resident #67's meal intake records, documented by STNA staff assigned to provide care to the resident reflected the resident had decreased intake during her stay. On 04/25/23 breakfast and lunch intakes were 1-25% and dinner 50%. On 04/26/23 breakfast and dinner intakes were 75% and lunch was 25%. On 04/27/23 breakfast intake was 75% and lunch and dinner intakes were 50%. On 04/28/23 breakfast intake was 75%, lunch 100%, and dinner was 50%. On 04/29/23 and 04/30/23 all three meals the resident had 75% intake. On 05/01/23 the resident refused breakfast, lunch intake was 25% and dinner intake was 50%. On 05/02/23 breakfast and lunch intakes were 50% and dinner was 75%. On 05/03/23 breakfast intake was 1-25%, lunch intake was 50%, and dinner intake was 25%. On 05/04/23 breakfast and dinner intakes were 50% and lunch was 25%. On 05/05/23 breakfast and dinner intakes were 25% and lunch was 75%. On 05/06/23 breakfast intake was 25% and lunch and dinner intakes were 50%. On 05/07/23 breakfast intake was 75%, lunch was 1-25%, and dinner was 25%. On 05/08/23 breakfast and dinner intakes were 25% and lunch was 50%. On 05/09/23 only two meal intakes were recorded. The breakfast meal intake was 25%, lunch was 50%, and there was no documented intake for dinner. On 05/10/23 breakfast and dinner intakes were 1-25% and lunch was 75%. On 05/11/23 breakfast intake was 75% and lunch and dinner were refused. There were no meal intakes recorded for 05/12/23. On 05/13/23 breakfast was 1-25% and lunch and dinner were 25%. On 05/14/23 the resident did not have any breakfast. 366478 Page 3 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0580 Level of Harm - Minimal harm or potential for actual harm Review of Resident #67's paper and EMR revealed no evidence the resident received an alternative when consuming less than 50% of her meals. Review of Resident #67's treatment administration records dated 05/01/23 to 05/13/23 revealed the resident's 24-hour fluid intakes were documented to range from 360 ml to 600 ml during this time period. Residents Affected - Few Review of Resident #67's occupational therapy note dated 05/12/23 at 1:44 P.M. revealed Certified Occupational Therapy Assistant (COTA) #203 was not able to keep the resident's attention to task due to the resident falling asleep and confusion. COTA #203 took the resident to nurse's station completing communication with nursing pertaining to resident status. The resident was not unable to participate in therapy session this date secondary to mental status and lethargy. The note indicated nursing was looking into a possible urinary tract infection (UTI). Review of Resident #67's nursing progress notes, dated 05/12/23 through 05/13/23 revealed no evidence the physician was notified of the resident's change in condition reported by COTA #203. Review of Resident #67's health status progress note, dated 05/14/23 at 11:58 A.M. and authored by LPN #174 revealed the resident was in the dining room with family for lunch and not acting like herself. She had increased confusion, lethargy, and low blood pressure (91/64). The family requested the resident to be sent to the ER for evaluation where she was admitted . Review of the fire department patient care record form for Resident #67, dated 05/14/23 revealed the fire department arrived (on 05/14/23) to the facility at 12:02 P.M., arrived at the resident's bedside at 12:03 P.M., departed the facility at 12:16 P.M., arrived at the (hospital) destination at 12:22 P.M., and transferred the resident at 12:25 P.M. The call from the facility was for an [AGE] year-old requiring transport to hospital. Upon arrival, fire department staff found a patient sitting in a chair with her family. The family stated she was not acting like herself. The patient did answer several of the questions asked of her but not all. The patient was complaining about her (bake?) being sore. Checked vitals while sitting and family stated the last time the resident was known to be feeling well was last Friday. The resident's vital signs were obtained which showed a blood pressure of 84/56 (hypotensive), pulse 90 (tachycardic) per minute, respirations 16 per minute, and pulse ox (oxygen saturation) of 96%. Review of Resident #67's hospital emergency room documentation dated 05/14/23 from 1:35 P.M. to 2:52 P.M. revealed the resident presented to the emergency room with complaints of altered mental status. The patient was sent from nursing home for lethargy. The resident's daughter was at bedside to assist with the history as patient did not answer questions. Family stated the patient was normally verbal and could walk; however noticed today she was just lying in bed and staring up. Patient would occasionally complain of having left hip pain. History was limited secondary to patient not answering questions. The resident's general appearance was chronically ill appearing, cachectic (a general state of ill health involving marked weight loss and muscle tone) and appeared very dehydrated on exam. The patient's mucus membranes were dry. The resident had a Grade 2 pressure ulcer over the sacrum; her skin was warm and dry with poor skin turgor. The patient would respond to painful stimuli but not verbal stimuli, would move all four extremities if agitated. The resident's blood pressure initially was hypotensive with a pressure of 70/30 (normal 120/80). The ER gave patient a fluid bolus to determine if her (blood) pressure was responsive. The patient does have a history of congestive heart failure, but it was felt the patient needed the intravenous fluids to tolerate the prescribed intravenous fluid orders. The patient was very thin and required the physician's vigilant attention to 366478 Page 4 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0580 prevent deterioration (sepsis, hypotension). Level of Harm - Minimal harm or potential for actual harm Review of the hospital admission notes, dated 05/14/23 revealed the resident was admitted to the hospital with diagnoses including toxic metabolic encephalopathy related to acute kidney injury, sepsis, urinary tract infection likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting, rib exposure with a body mass index under 19, and a Stage II pressure ulcer to the left buttocks. Residents Affected - Few On 05/24/23 at 10:32 A.M. interview with Regional Registered Dietitian (RRD) #197 verified Resident #67's diet was upgraded on 04/25/23 to a regular texture diet from a mechanical soft diet, however the dietary department never received the order or communication form. The only order/communication form the dietary department had received was the admission order for the mechanical soft textured diet. On 05/24/23 at 11:30 A.M. interview with ADON #120 revealed there was no documentation assessing the resident on 05/12/23 or 05/13/23. The ADON revealed the resident was skilled and should have had documentation completed at least once a day. ADON #120 revealed the resident was ordered a COVID test, laboratory testing including a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) on 05/11/23 without any indication or documentation why it was ordered. The resident was also ordered a chest x-ray on 05/11/23 that indicated possible fluid overload, however there was no documentation to support the order or assessment of the resident after receiving the x-ray results. ADON #120 revealed she did not believe Resident #67 had a change of condition on 05/12/23 or 05/13/23; however there was no documented evidence to support the resident's condition except a phone interview that was completed on 05/24/23 by ADON #120, with LPN #174 and after the above concerns that had been identified by the State survey agency. On 05/24/23 at 12:33 P.M. interview with Resident #67's family, Family Member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. The family member stated when the squad transferred Resident #67 to the bed in the emergency room the emergency room (ER) nurse looked at Resident #67's skin and reported the resident had a bad pressure ulcer on her buttocks. During this interview and a subsequent interview on 05/31/23 at 2:19 P.M. Family Member #199 reported she had visited the resident in the facility on 05/12/23. On 05/14/23 when visiting, the family member felt the resident was confused and lethargic and asked the nurse to assess the resident. The resident's blood pressure was low, and she had asked the nurse to transfer the resident to the emergency room. The facility nurse reported to her (Family Member #199) and the ambulance driver Resident 67's had been like this for three days and had not eaten or consumed fluids. Family Member #199 revealed the facility had reported to them the resident's weight was 113 pounds but in the emergency room, the family was told the resident weighed 85 pounds. The family member denied the resident or herself reporting the resident weighed 85 pounds to hospital staff. Family Member #199 reported the family didn't understand why the resident was on fluid restriction because she had not been on a fluid restriction or special diet when she was in the hospital (prior to the nursing home admission). The family member also indicated the resident would not eat the mechanically altered diet provided by the facility. After being treated in the hospital, the resident was discharged to a different skilled nursing facility in the area and had done a complete 180 degree turn around (improvement). Family Member #199 revealed she had shown co-workers pictures of the resident while she was at the facility compared to the current skilled nursing facility and they couldn't believe the improvement. The resident had gained weight and was able to use Facetime and communicate with family. The resident reported to family that facility staff never checked on her, which she felt was accurate as when family visited no staff ever came in to check on the resident. 366478 Page 5 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/24/23 at 1:16 P.M. interview with STNA #124, STNA #188, and LPN #153 with RRD #197 revealed the STNA staff reported they did not include fluids as part of their meal intake documentation. The LPN reported she only documented on the treatment administration record (TAR) the fluids nursing staff administered. The STNA and LPN confirmed they do not calculate or document the fluids dietary provided. RRD #197 reported she was not aware staff were not monitoring or documenting the fluids dietary was providing on the meal trays. She thought 25% of the meal intakes staff were recording under the task tab in the EMR include fluids provided at mealtime. The RRD reported all residents, no matter the diagnosis, should have fluid monitoring. Nutritional intakes were more important than solid intakes. During the interview, RRD #197 verified Resident #67 was not receiving adequate fluids while in the facility especially given the admitting diagnosis to the hospital on [DATE]. On 05/24/23 at 3:30 P.M. interview with the Administrator confirmed the RD had ordered a house supplement, 120 ml twice daily on 04/27/23, however the order was never implemented, and the resident did not receive the supplement. On 05/25/23 at 11:36 A.M. interview with COTA #203 revealed Resident #67 was more confused and lethargic (on 05/12/23) so she took the resident back to the nurse's station to report the change of condition to the nurse. COTA #203 stated the nurse thought the resident had a urinary tract infection (UTI). On 05/25/23 at 12:45 P.M. interview with STNA #114 revealed she provided care to Resident #67 during the resident's stay. STNA #114 revealed the resident was confused but could let you know her needs. The resident would ask for fluids; however, since she was on a fluid restriction the nurses would have to provide fluids to the resident. STNA #114 revealed STNA staff did not monitor or document resident fluids intakes. The STNA indicated the resident was a tiny bony lady and required encouragement to eat, drink, and even to get out of bed. On 05/25/23 at 1:36 P.M. interview with Resident #67's primary care physician, who was also the facility medical director, Medical Director #196 revealed he was not aware of the nutritional concerns with Resident #67 including the failure to provide nutritional supplements, the lack of nutritional support with the resident being admitted to the facility with a pressure ulcer as well as developing a pressure ulcer during her stay, the resident's decreased meal intakes and fluid intakes, the facility not providing the resident the correct diet, the presence of thrush for several days before it was reported or the resident's condition change over the last few days of her stay until the time of this interview. The MD reported he was the only provider for the facility and he should be notified with changes in the resident's condition. On 05/25/23 at 3:16 P.M. interview with STNA #161 revealed Resident #67 was on a mechanical soft diet and would try to feed herself. STNA #161 recalled the family wanted the resident's diet upgraded to a regular diet due to the resident's poor intake. The STNA stated the resident's family would bring drinks and food in for Resident #67 even though she was on a fluid restriction and a mechanical soft diet. On 05/31/23 at 9:30 A.M. interview with Dietary Manger (DM) #104 confirmed Resident #67 never received the ordered upgrade to a regular diet because the order and/or communication form (used to notify dietary of orders or changes) was never sent to the dietary department. DM #104 verified the only written communication received about Resident #67's diet orders was on admission that indicated the resident required a mechanical soft diet. 366478 Page 6 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0580 Level of Harm - Minimal harm or potential for actual harm On 05/31/23 at 10:09 A.M. interview with Manger of Clinical Service #195 confirmed the physician had only seen Resident #67 once during her stay at the facility and that was on 04/25/23 when he performed the resident's history of physical. This deficiency represents non-compliance investigated under Complaint Number OH00142901. Residents Affected - Few 366478 Page 7 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of hospital records, review of therapy notes, review of staff telephone statements, and interviews the facility failed to ensure pressure ulcers were timely identified. This affected one resident (Resident #67) of three residents reviewed for pressure ulcers. The census was 66. Residents Affected - Few Findings included: Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Review of Resident #67's admission assessment dated [DATE] revealed the resident had several surgical wounds, abrasion to left inner thigh, moisture associated skin damage to the buttocks, and a deep tissue pressure injury (DTPI) area (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) to the coccyx measuring 4.9 centimeter (cm) by 6.4 cm by unable to determine (UTD). The DTPI area to the coccyx was red to purple non-blanching area with peeling tissue, no drainage, peri wound appears normal and a skin tear to left elbow. Review of Resident #67 pressure ulcer assessment completed on 04/24/23 revealed the resident was at risk for pressure ulcer development. Review of Resident #67's alteration of skin integrity plan of care dated 04/26/23 revealed check body weekly and to notify physician and family of changes as needed. Review of Resident #67's coccyx pressure ulcer assessment completed on 05/02/23 indicated the resident had a DTPI to the coccyx had resolved. Review of Resident #67's paper record and EMR revealed no evidence of skin alteration to buttocks/coccyx or treatment to buttocks/coccyx from 05/02/23 through 05/14/23. Review of Resident #67's medication and treatment records dated 05/08/23 revealed a weekly skin assessment was completed, however there was no indication of the findings of the skin assessment. Review of Resident #67's physical therapy notes authored by Physical Therapist (PT) #204 and Physical Therapy Assistant (PTA) #205 dated 05/09/23, 05/10/23, 05/11/23, and 05/12/23 revealed the resident had reported pain and a sore on buttocks. Review of Resident #67's paper record and EMR revealed no evidence Resident #67's complaints of pain and sore buttocks that were reported to therapy 05/09/23, 05/10/23, 05/11/23, and 05/12/23 , by Resident #67, had been assessed by nursing. Review of Resident #67's shower sheet dated 05/13/23 revealed the resident had no areas and the skin was intact, however review of Resident #67's skin assessment completed on 05/10/23 indicated there 366478 Page 8 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was skin tear to the right elbow and surgical incision to the left lateral thigh. There was no evidence that the right elbow or left lateral thigh skin alterations had resolved. Review of the fire department patient care record form for Resident #67 dated 05/14/23 revealed the fire department arrived at the facility at 12:02 P.M., arrived to the resident at 12:03 P.M., departed the facility at 12:16 P.M., arrived at destination at 12:22 P.M., and transferred resident at 12:25 P.M. (to the ER bed). Time elapsed from pick up to transfer to ER care was 23 minutes. Review of Resident hospital notes dated 05/14/23 revealed the resident had a Stage II pressure ulcer on the buttocks upon arrival to the emergency room. Review of two handwritten unsigned statements dated 05/24/23 revealed STNA #174 was interviewed via phone on 05/24/23 by ADON #191 and reported the resident had no open areas on her body on Sunday 05/14/23. The second statement was LPN #151 revealed the resident had no pressure areas to coccyx on 05/14/23 and a patch was used for comfort. The statements were not part of the resident's medical record and none of the documentation in the medical record supported the use of a patch for comfort or the area had been observed/assessed by the nurse. Interview on 05/24/23 at 12:33 P.M., with Resident #67's family member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. When the squad transferred Resident #67 to the bed in the emergency room the ER nurse looked at Resident #67's skin and reported she had a bad pressure ulcer on her buttocks. The family member denied the resident waiting to be assessed/treated once she arrived in the emergency room and was assisted from the transport cot to the ER bed upon the resident's arrival to the ER. The nurse assisted with moving the resident from the transport cot to the ER bed and identified the resident's pressure ulcer at that time. Interview on 05/24/23 at 12:36 P.M with the ADON #120 and ADON #191 confirmed the resident had two documented skin (right elbow and left lateral thigh) alterations on 05/13/23 confirming the shower sheet dated 05/13/23 was inaccurate as skin alterations present had not been identified on the document. Interview on 05/25/23 at 12:30 P.M., with Physical Therapist (PT) #204 revealed the resident was a skinny little thing. He did not visualize Resident #67's buttocks, but the resident had reported it was sore. The resident spent most of her time in bed. Interview on 05/25/23 at 12:51 P.M., with Physical Therapy Assistant (PTA) #205 revealed she had never visualized Resident #67's buttocks, however the resident reported she had a bedsore and complained of pain and this information was reported to the nursing staff as well as documented in the therapy notes. Attempts to reach LPN #174 and STNA #151 were unsuccessful. Messages were left for the staff to return the call however, no return call was provided. This deficiency represent non-compliance investigated under Complaint Number OH00142901. 366478 Page 9 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to timely identify and treat a urinary tract infection for Resident #67. This affected one resident (#67) of four sampled residents. Findings include: Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). Review of the resident's hospital records (prior to facility admission) dated 04/19/23 to 04/24/23 revealed the resident had a history of severe protein calorie malnutrition and had acute on chronic renal failure related to poor intake. Review of Resident #67's fluid restriction worksheet and physician's orders, dated 04/25/23 revealed the resident was not to exceed a total daily fluid intake of 1500 milliliters (ml); 720 ml dietary and 780 ml nursing. The worksheet noted one cup of 240 ml of fluids on each meal tray. Record review revealed a plan of care, dated 04/26/23 related to altered health maintenance due to progress physical and mental status. Interventions included to monitor for signs and symptoms of cardiac distress and report to the cardiac and vascular doctor if any weight gain/loss, edema, fatigue, chest pain, confusion, nausea, decreased urinary output, or increased laboratory testing (BUN/Creatine). Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/23 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status of three out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use, extensive assistance from one staff for dressing, supervision from staff for eating, and limited assistance from one staff for personal hygiene. The resident had no impairment to the upper or lower body and used a walker. The MDS assessment revealed Resident #67 was 61 inches in height and weighed 113 pounds; had no swallowing issues, weight loss, or dental problems. The resident was at risk for pressure ulcer development and had one unstageable deep tissue injury on admission located on the coccyx. Review of Resident #67's physician progress notes revealed no evidence the resident was assessed/seen by a physician and/or other designated healthcare provider on behalf of the physician during the resident's stay, with the exception of 04/25/23 when a history and physical was completed. Review of Resident #67's treatment administration records dated 05/01/23 to 05/13/23 revealed the resident's 24-hour fluid intakes were documented to range from 360 ml to 600 ml during this time period. Review of Resident #67's occupational therapy note dated 05/12/23 at 1:44 P.M. revealed Certified 366478 Page 10 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0690 Level of Harm - Minimal harm or potential for actual harm Occupational Therapy Assistant (COTA) #203 was not able to keep the resident's attention to task due to the resident falling asleep and confusion. COTA #203 took the resident to nurse's station completing communication with nursing pertaining to resident status. The resident was not unable to participate in therapy session this date secondary to mental status and lethargy. The note indicated nursing was looking into a possible urinary tract infection (UTI). Residents Affected - Few Record review revealed no evidence of any assessment or additional follow up on 05/12/23 related to the resident possibly having a urinary tract infection. Review of Resident #67's nursing progress notes, dated 05/12/23 through 05/13/23 revealed no evidence the physician was notified of the resident's change in condition reported by COTA #203. Review of Resident #67's health status progress note, dated 05/14/23 at 11:58 A.M. and authored by LPN #151 revealed the resident was in the dining room with family for lunch and not acting like herself. She had increased confusion, lethargy, and low blood pressure (91/64). The family requested the resident to be sent to the ER for evaluation where she was admitted . Review of the fire department patient care record form for Resident #67, dated 05/14/23 revealed the fire department arrived (on 05/14/23) to the facility at 12:02 P.M., arrived at the resident's bedside at 12:03 P.M., departed the facility at 12:16 P.M., arrived at the (hospital) destination at 12:22 P.M., and transferred the resident at 12:25 P.M. The call from the facility was for an [AGE] year-old requiring transport to hospital. Upon arrival, fire department staff found a patient sitting in a chair with her family. The family stated she was not acting like herself. The patient did answer several of the questions asked of her but not all. The patient was complaining about her (bake?) being sore. Checked vitals while sitting and family stated the last time the resident was known to be feeling well was last Friday. The resident's vital signs were obtained which showed a blood pressure of 84/56 (hypotensive), pulse 90 (tachycardic) per minute, respirations 16 per minute, and pulse ox (oxygen saturation) of 96%. Review of Resident #67's hospital emergency room documentation dated 05/14/23 from 1:35 P.M. to 2:52 P.M. revealed the resident presented to the emergency room with complaints of altered mental status. The patient was sent from nursing home for lethargy. The resident's daughter was at bedside to assist with the history as patient did not answer questions. Family stated the patient was normally verbal and could walk; however noticed today she was just lying in bed and staring up. Patient would occasionally complain of having left hip pain. History was limited secondary to patient not answering questions. The resident's general appearance was chronically ill appearing, cachectic (a general state of ill health involving marked weight loss and muscle tone) and appeared very dehydrated on exam. The patient's mucus membranes were dry. The resident had a Grade 2 pressure ulcer over the sacrum; her skin was warm and dry with poor skin turgor. The patient would respond to painful stimuli but not verbal stimuli, would move all four extremities if agitated. The resident's blood pressure initially was hypotensive with a pressure of 70/30 (normal 120/80). The ER gave patient a fluid bolus to determine if her (blood) pressure was responsive. The patient does have a history of congestive heart failure, but it was felt the patient needed the intravenous fluids to tolerate the prescribed intravenous fluid orders. The patient was very thin and required the physician's vigilant attention to prevent deterioration (sepsis, hypotension). Review of the hospital admission notes, dated 05/14/23 revealed the resident was admitted to the hospital with diagnoses including toxic metabolic encephalopathy related to acute kidney injury, sepsis, urinary tract infection likely due to poor oral intakes and severe protein calorie malnutrition 366478 Page 11 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with temporal wasting, rib exposure with a body mass index under 19, and a Stage II pressure ulcer to the left buttocks. On 05/24/23 at 11:30 A.M. interview with ADON #120 revealed there was no documentation assessing the resident on 05/12/23 or 05/13/23. The ADON revealed the resident was skilled and should have had documentation completed at least once a day. ADON #120 revealed the resident was ordered a COVID test, laboratory testing including a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) on 05/11/23 without any indication or documentation why it was ordered. The resident was also ordered a chest x-ray on 05/11/23 that indicated possible fluid overload, however there was no documentation to support the order or assessment of the resident after receiving the x-ray results. ADON #120 revealed she did not believe Resident #67 had a change of condition on 05/12/23 or 05/13/23; however there was no documented evidence to support the resident's condition except a phone interview that was completed on 05/24/23 with LPN #151 and after the above concerns that had been identified by the State survey agency. On 05/24/23 at 12:33 P.M. interview with Resident #67's family, Family Member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. The family member stated when the squad transferred Resident #67 to the bed in the emergency room the emergency room (ER) nurse looked at Resident #67's skin and reported the resident had a bad pressure ulcer on her buttocks. During this interview and a subsequent interview on 05/31/23 at 2:19 P.M. Family Member #199 reported she had visited the resident in the facility on 05/12/23. On 05/14/23 when visiting, the family member felt the resident was confused and lethargic and asked the nurse to assess the resident. The resident's blood pressure was low, and she had asked the nurse to transfer the resident to the emergency room. The facility nurse reported to her (Family Member #199) and the ambulance driver Resident 67's had been like this for three days and had not eaten or consumed fluids. On 05/24/23 at 1:16 P.M. interview with STNA #124, STNA #188, and LPN #153 with RRD #197 revealed the STNA staff reported they did not include fluids as part of their meal intake documentation. The LPN reported she only documented on the treatment administration record (TAR) the fluids nursing staff administered. The STNA and LPN confirmed they do not calculate or document the fluids dietary provided. RRD #197 reported she was not aware staff were not monitoring or documenting the fluids dietary was providing on the meal trays. She thought 25% of the meal intakes staff were recording under the task tab in the EMR include fluids provided at mealtime. The RRD reported all residents, no matter the diagnosis, should have fluid monitoring. Nutritional intakes were more important than solid intakes. During the interview, RRD #197 verified Resident #67 was not receiving adequate fluids while in the facility especially given the admitting diagnosis to the hospital on [DATE]. On 05/25/23 at 11:36 A.M. interview with COTA #203 revealed Resident #67 was more confused and lethargic (on 05/12/23) so she took the resident back to the nurse's station to report the change of condition to the nurse. COTA #203 stated the nurse thought the resident had a urinary tract infection (UTI). The COTA was unable to recall who the nurse was she reported the resident's condition to. On 05/25/23 at 12:45 P.M. interview with STNA #114 revealed she provided care to Resident #67 during the resident's stay. STNA #114 revealed the resident was confused but could let you know her needs. The resident would ask for fluids; however, since she was on a fluid restriction the nurses would have to provide fluids to the resident. STNA #114 revealed STNA staff did not monitor or document resident fluids intakes. The STNA indicated the resident was a tiny bony lady and required encouragement to eat, drink, and even to get out of bed. 366478 Page 12 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/25/23 at 1:36 P.M. interview with Resident #67's primary care physician, who was also the facility medical director, Medical Director #196 revealed he was not aware of the resident's condition change over the last few days of her stay until the time of this interview. On 05/31/23 at 10:09 A.M. interview with Manger of Clinical Service #195 confirmed the physician had only seen Resident #67 once during her stay at the facility and that was on 04/25/23 when he performed the resident's history of physical. This deficiency represents non-compliance investigated under Complaint Number OH00142901. 366478 Page 13 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of medical nutrition therapy best practice guidance and interview, the facility failed to develop and implement comprehensive, individualized and adequate nutritional interventions and complete accurate weight monitoring to meet the nutritional needs and prevent weight loss for all residents. Residents Affected - Few Actual Harm occurred on 04/24/23, when the facility failed to implement comprehensive and individualized nutritional interventions, failed to ensure discharge orders regarding resident fluid intake were properly addressed, failed to timely implement dietician recommendations for nutritional support/supplements, failed to provide the resident with the correct diet, failed to timely address the resident's reports of mouth pain/thrush and failed to notify the resident's physician of condition changes related to lethargy and decreased meal intakes. On 05/14/23 Resident #67 was transferred to the hospital, admitted and diagnosed with toxic metabolic encephalopathy (a condition of acute global cerebral dysfunction manifested by altered consciousness, behavior changes, and/or seizures in the absence of primary structural brain disease or direct central nervous system infection with causes including infections, dehydration and malnutrition) related to acute kidney injury, sepsis, urinary tract infections likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting (loss of temporalis muscle mass commonly seen in cases of catabolism (destructive metabolism) and/or generalized nutritional deficiency), rib exposure with a body mass index less than 19. This affected three residents (#4, #18 and #67) of four residents reviewed for nutrition. The facility identified four residents (#4, #18, #34, and #43) with significant, unplanned weight loss. The facility census was 66. Findings include: 1. Review of Resident #67's hospital records (prior to facility admission) dated 04/19/23 to 04/24/23 revealed the resident had a history of severe protein calorie malnutrition and had acute on chronic renal failure related to poor intake. Review of the hospital discharge summary plan dated, 04/24/23 revealed the resident had an echocardiogram (a scan used to look at the heart and near-by blood vessels) during her hospitalization that showed a grade one diastolic dysfunction (heart cannot fully fill during the diastolic part of the heartbeat). The resident's discharge orders revealed the resident required a cardiac 1500 milliliter (ml) fluid restriction daily (used to avoid overloading your heart if you have heart failure as more fluid in your bloodstream makes it harder for your heart to pump) and a minced moisture texture diet. Hospital discharge documentation noted the resident's stay was expected to be less 30-days at the skilled nursing facility. The resident's discharge instructions included a recommendation if you were told you had heart failure weigh yourself daily at the same time each day. Call your doctor and report right away if you gain more than three (3) pounds or more in one day or if you gain five (5) pounds or more in one week or if you have any heart failure symptoms. Closed record review revealed Resident #67 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident's diagnoses included orthopedic aftercare due to a displaced intertrochanter fracture of the left femur, type two diabetes, muscle weakness, dysphagia (difficulty swallowing), heart disease, stage three chronic kidney disease, hypertension, falls and ectopic kidney (a kidney located below, above or on the opposite side of the kidney's normal position in the urinary tract). 366478 Page 14 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Level of Harm - Actual harm Residents Affected - Few Review of Resident #67 electronic medical record (EMR) revealed a documented weight on 04/24/23 of 113.0 pounds. Review of the resident's physician's orders (from 04/2023 through 05/14/23) revealed no physician's order for any type of weight monitoring. Record review revealed an admission order, dated 04/24/23 for a no added salt (NAS) mechanical soft diet. On 04/25/23 the resident's diet was upgraded to a regular texture diet; however this was not communicated to the dietary department. Review of Resident #67's fluid restriction worksheet and physician's orders, dated 04/25/23 revealed the resident was not to exceed a total daily fluid intake of 1500 milliliters (ml); 720 ml dietary and 780 ml nursing. The worksheet noted one cup of 240 ml of fluids on each meal tray. Review of Resident #67's oral assessment dated [DATE] and authored by the Director of Nursing (DON) revealed the resident had one to three decayed or broken teeth and no dentures. Record review revealed a plan of care, dated 04/26/23 related to altered health maintenance due to progress physical and mental status. Interventions included to monitor for signs and symptoms of cardiac distress and report to the cardiac and vascular doctor if any weight gain/loss, edema, fatigue, chest pain, confusion, nausea, decreased urinary output, or increased laboratory testing (BUN/Creatine). Interventions also included to provide diet ordered; if less than 50% consumed offer supplements as ordered (the resident had no orders for nutritional supplements at this time). Stress the importance of good nutrition and how it promotes healing and increases resistance. Review of Resident #67's speech notes authored by Speech and Language Pathologist (SLP) #201 dated 04/26/23 revealed the resident ate slightly better after speech sat and ate their own individual items while the resident ate. The resident reported the food was bland, Mrs. Dash was used and the resident reported the food was better. Review of Resident #67's nutrition risk tool, dated 04/27/23 and authored by Registered Dietician (RD) #198 revealed the resident was at moderate risk for nutritional decline due to having a moderate decrease in food intake, no weight loss in three months, able to get out of bed/chair but does not go out, BMI 21 to less than 23, had suffered psychological stress or acute disease in the past three months, and no psychological problems. There were no guidelines to direct staff on how to proceed with a resident assessed with nutritional risks. Review of Resident #67's dietary assessment, dated 04/27/23 and authored by RD #198 revealed the resident was hospitalized for an intertrochanter fracture and had undergone surgery (gamma nailing) on 04/20/23 (during the resident's hospitalization). The resident lived at home (prior to the hospitalization), and family had provided her with breakfast and dinner. The resident reported she would often forget to eat lunch due to being home alone. The resident reported she had recently started drinking Boost (a nutritional supplement) once daily due to weight loss and lack of intake. The assessment noted, a no added salt (NAS) with thin liquids and regular textured solids diet. The current diet provided 2454 calories and 92 grams of protein. The resident reported her appetite was fair and slowly improving. The resident fed herself with no noted chewing or swallowing problems. Documentation indicated the resident was consuming 25-50% of meal trays. The dietary note indicated the RD would order a house supplement, 120 milliliters (ml) twice daily to provide an additional 240 calories and 20 grams of protein. The resident's weight was noted to be 113 pounds with a BMI of 21.3. The resident's usual body weight (UBW) was 130 pounds and last weight in 09/2022 showed a weight loss of 17 pounds in seven months which was significant. The resident had no edema noted. The dietary assessment 366478 Page 15 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Level of Harm - Actual harm Residents Affected - Few also reflected the resident had a deep tissue injury (pressure ulcer) to the coccyx per a skin grid assessment completed on 04/25/23. Resident #67 was noted to be at risk for decline in nutritional status per the Nutrition Risk Tool with a score of 9 (moderate risk for nutritional decline). The resident had nutritional diagnoses including malnutrition, chronic illness, severe muscle/fat loss, weight loss, and suboptimal intakes. Nutritional interventions included to discuss the importance of adequate nutrition to help aid in wound healing, encourage adequate calories, protein, nutrition supplements, and micronutrients to help in wound healing, encourage oral intake with at least 50% consumption at mealtimes, encourage snacking frequently between meals, and encourage compliance with fluid restrictions. Nutrition monitoring and evaluation included monitoring weights via weight report (paper weight book), monitor intakes, and skin integrity. The nutrition goals included the resident would consume at least 50% of meals, snack once daily, and consume Prostat (supplement) 30 ml daily with 100% consumption and house supplement 120 ml twice daily with 100% consumption. Review of Resident #67's paper medical record and electronic medical record (EMR) revealed no evidence a house supplement was ordered or administered to Resident #67 during the residents stay. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/23 revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status of three out of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toilet use, extensive assistance from one staff for dressing, supervision from staff for eating, and limited assistance from one staff for personal hygiene. The resident had no impairment to the upper or lower body and used a walker. The MDS assessment revealed Resident #67 was 61 inches in height and weighed 113 pounds; had no swallowing issues, weight loss, or dental problems. The resident was at risk for pressure ulcer development and had one unstageable deep tissue injury on admission located on the coccyx. On 05/02/23 Licensed Practical Nurse (LPN) #192 documented in the electronic medical record the resident weighed 113.2 pounds. On 05/10/23 RD #198 entered a weight of 112.5 pounds for the resident in the electronic medical record. On 05/11/23 Registered Nurse (RN) #136 documented the resident weighed 113.2 pounds in the electronic medical record. The resident was discharged to the hospital on [DATE]. Review of the facility paper weight book revealed the week of 05/10/23 there were no documented weights for Resident #67 or for residents on the 200, 300, 400, or 500 halls. Resident #67's name was highlighted yellow. There was a handwritten note by an unidentified author that indicated weights need to be completed by 05/16/23, however floors 200, 300, 400, and 500 were not completed by 05/16/23 and the Director of Nursing (DON) was notified by an unidentified staff member. On 05/04/23 a speech note authored by Speech Therapist (SLP) #201 indicated the resident remarked that it hurt to eat. Speech therapy noted something that appeared ulcer-like and hurt whenever even light pressure was applied (to the resident's mouth). The note indicated the nurse was made aware and was going to have the physician look at it first before making a referral to the dentist. The nurse who was notified was not identified in the SLP documentation. On 05/05/23 a speech note authored by SLP #201 indicated the resident was still complaining of her mouth hurting when eating. The note indicated nursing was aware and would have the physician look at it when he comes in. Review of Resident #67's therapy note dated 05/08/23 and authored by SLP #201, revealed ST #201 366478 Page 16 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Level of Harm - Actual harm Residents Affected - Few called Resident #67's family (Family Member #199) regarding the resident's diet order. Resident #67's diet was a regular diet, however the diet slip on the meal tray had not been updated. The diet slip was now updated, and the family was notified the resident would receive the correct diet. On 05/09/23 a speech note authored by SLP #201 indicated the resident had complaints of mouth pain when eating. Nursing and physician aware. The note did not indicate which nurse was aware or who made the physician aware. Review of Resident #67's (nursing) progress notes dated 04/25/23 to 05/09/23 revealed no documented assessment or evidence of the resident's reported complaints of mouth pain. Although the resident's dietary assessment, completed on 04/27/23 reflected frequent snacking between meals, review of snack intakes, dated 05/08/23 to 05/14/23 revealed the resident was provided a snack on 05/10/23, 05/12/13, and 05/13/23. She refused a snack on 05/08/23 and there was no documentation of snacks on 05/09/23 or 05/11/23. Review of Resident #67's paper record and EMR revealed no evidence the physician was notified of Resident #67's complaints of pain that were reported to therapy by the resident. Review of a progress note dated 05/10/23 at 11:10 P.M. and authored by ADON #120 revealed the Resident #67 was complaining of sores in (her) mouth and mouth pain. The resident was noted to have inflamed gums and few white patches/sores noted. The physician was notified and ordered Clotrimazole (antifungal) lozenges for 14 days due to thrush (yeast infection in the mouth). Review of Resident #67's physician progress notes revealed no evidence the resident was assessed/seen by a physician and/or other designated healthcare provider on behalf of the physician during the resident's stay, with the exception of 04/25/23 when a history and physical was completed. Review of Resident #67's meal intake records, documented by STNA staff assigned to provide care to the resident reflected the resident had decreased intake during her stay. On 04/25/23 breakfast and lunch intakes were 1-25% and dinner 50%. On 04/26/23 breakfast and dinner intakes were 75% and lunch was 25%. On 04/27/23 breakfast intake was 75% and lunch and dinner intakes were 50%. On 04/28/23 breakfast intake was 75%, lunch 100%, and dinner was 50%. On 04/29/23 and 04/30/23 all three meals the resident had 75% intake. On 05/01/23 the resident refused breakfast, lunch intake was 25% and dinner intake was 50%. On 05/02/23 breakfast and lunch intakes were 50% and dinner was 75%. On 05/03/23 breakfast intake was 1-25%, lunch intake was 50%, and dinner intake was 25%. On 05/04/23 breakfast and dinner intakes were 50% and lunch was 25%. On 05/05/23 breakfast and dinner intakes were 25% and lunch was 75%. On 05/06/23 breakfast intake was 25% and lunch and dinner intakes were 50%. On 05/07/23 breakfast intake was 75%, lunch was 1-25%, and dinner was 25%. On 05/08/23 breakfast and dinner intakes were 25% and lunch was 50%. On 05/09/23 only two meal intakes were recorded. The breakfast meal intake was 25%, lunch was 50%, and there was no documented intake for dinner. On 05/10/23 breakfast and dinner intakes were 1-25% and lunch was 75%. On 05/11/23 breakfast intake was 75% and lunch and dinner were refused. There were no meal intakes recorded for 05/12/23. On 05/13/23 breakfast was 1-25% and lunch and dinner were 25%. On 05/14/23 the resident did not have any breakfast. Review of Resident #67's paper and EMR revealed no evidence the resident received an alternative when consuming less than 50% of her meals. Review of Resident #67's treatment administration records dated 05/01/23 to 05/13/23 revealed the 366478 Page 17 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 resident's 24-hour fluid intakes were documented to range from 360 ml to 600 ml during this time period. Level of Harm - Actual harm Review of Resident #67's occupational therapy note dated 05/12/23 at 1:44 P.M. revealed Certified Occupational Therapy Assistant (COTA) #203 was not able to keep the resident's attention to task due to the resident falling asleep and confusion. COTA #203 took the resident to nurse's station completing communication with nursing pertaining to resident status. The resident was not unable to participate in therapy session this date secondary to mental status and lethargy. The note indicated nursing was looking into a possible urinary tract infection (UTI). Residents Affected - Few Review of Resident #67's nursing progress notes, dated 05/12/23 through 05/13/23 revealed no evidence the physician was notified of the resident's change in condition reported by COTA #203. Review of Resident #67's health status progress note, dated 05/14/23 at 11:58 A.M. and authored by LPN #151 revealed the resident was in the dining room with family for lunch and not acting like herself. She had increased confusion, lethargy, and low blood pressure (91/64). The family requested the resident to be sent to the ER for evaluation where she was admitted . Review of the fire department patient care record form for Resident #67, dated 05/14/23 revealed the fire department arrived (on 05/14/23) to the facility at 12:02 P.M., arrived at the resident's bedside at 12:03 P.M., departed the facility at 12:16 P.M., arrived at the (hospital) destination at 12:22 P.M., and transferred the resident at 12:25 P.M. The call from the facility was for an [AGE] year-old requiring transport to hospital. Upon arrival, fire department staff found a patient sitting in a chair with her family. The family stated she was not acting like herself. The patient did answer several of the questions asked of her but not all. The patient was complaining about her (bake?) being sore. Checked vitals while sitting and family stated the last time the resident was known to be feeling well was last Friday. The resident's vital signs were obtained which showed a blood pressure of 84/56 (hypotensive), pulse 90 (tachycardic) per minute, respirations 16 per minute, and pulse ox (oxygen saturation) of 96%. Review of Resident #67's hospital emergency room documentation dated 05/14/23 from 1:35 P.M. to 2:52 P.M. revealed the resident presented to the emergency room with complaints of altered mental status. The patient was sent from nursing home for lethargy. The resident's daughter was at bedside to assist with the history as patient did not answer questions. Family stated the patient was normally verbal and could walk; however noticed today she was just lying in bed and staring up. Patient would occasionally complain of having left hip pain. History was limited secondary to patient not answering questions. The resident's general appearance was chronically ill appearing, cachectic (a general state of ill health involving marked weight loss and muscle tone) and appeared very dehydrated on exam. The patient's mucus membranes were dry. The resident had a Grade 2 pressure ulcer over the sacrum; her skin was warm and dry with poor skin turgor. The patient would respond to painful stimuli but not verbal stimuli, would move all four extremities if agitated. The resident's blood pressure initially was hypotensive with a pressure of 70/30 (normal 120/80). The ER gave patient a fluid bolus to determine if her (blood) pressure was responsive. The patient does have a history of congestive heart failure, but it was felt the patient needed the intravenous fluids to tolerate the prescribed intravenous fluid orders. The patient was very thin and required the physician's vigilant attention to prevent deterioration (sepsis, hypotension). Review of the hospital admission notes, dated 05/14/23 revealed the resident was admitted to the hospital with diagnoses including toxic metabolic encephalopathy related to acute kidney injury, 366478 Page 18 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Level of Harm - Actual harm Residents Affected - Few sepsis, urinary tract infection likely due to poor oral intakes and severe protein calorie malnutrition with temporal wasting, rib exposure with a body mass index under 19, and a Stage II pressure ulcer to the left buttocks. Review of Resident #67's hospital dietary notes, dated 05/15/23 revealed the resident was at high nutritional risk as evidence supported by diagnosis of severe malnutrition based on weight decrease. The resident's estimated energy needs were not being met due to poor oral intake. The note indicated to recommend Ensure high protein supplement three times a day and obtain updated weight. The resident had intravenous fluids running at 75 ml hour at the time of visit and refused to consume ordered supplements due to lethargy. The resident was only consuming 10% of Ensure due to spilling most of it. The note indicated the resident would be tried with a magic cup to see if it improved intakes. The physical findings revealed the patient had severe muscle and fat depletion per ASPEN malnutrition guidelines; her orbital region had a hollow look, depressions, dark circles and loose skin; the temple region had significant hollowing and depression; the shoulder region had a prominent protruding (the bony process on the shoulder blade); prominent protruding clavicle bone; very little thickness of tricep skin fold; in her scapular region she had very visible bones with depressions between ribs/scapula (shoulder blade) and shoulder/spine; severe depression of the inner thigh muscles; bones prominent with little muscle present around the knee; little to no muscle definition in the posterior calf region. On 05/23/23 at 1:47 P.M. and a follow-up interview at 3:05 P.M. with Registered Dietician (RD) #198 revealed resident weights were usually obtained on Tuesday and discussed on Wednesday during the facility's risk meetings. First the RD reported she was not responsible for notifying the physician or families of weight changes. The RD reported she would email the MDS nurse and DON of any significant weight changes. During the second interview at 3:05 P.M., the RD reported she was responsible for notifying the physician of weight loss and she had just forgotten she was responsible as she had previously stated she was not the responsible person for reporting weight loss to the physician. She stated she would only report to the physician if there was a 5% weight loss in one month or 10% weight loss in six months, but not sooner. The RD revealed she was not familiar with the federal regulations for nursing homes as she was just hired last month and had no prior nursing home experience. The RD #198 reported she did not have facility policies and procedures to reference, and stated she would follow the medical nutrition therapy best practices for high risk areas. On 05/24/23 at 10:32 A.M. interview with Regional Registered Dietitian (RRD) #197 verified Resident #67's diet was upgraded on 04/25/23 to a regular texture diet from a mechanical soft diet, however the dietary department never received the order or communication form. The only order/communication form the dietary department had received was the admission order for the mechanical soft textured diet. On 05/24/23 at 11:30 A.M. interview with ADON #120 revealed there was no documentation assessing the resident on 05/12/23 or 05/13/23. The ADON revealed the resident was skilled and should have had documentation completed at least once a day. ADON #120 revealed the resident was ordered a COVID test, laboratory testing including a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) on 05/11/23 without any indication or documentation why it was ordered. The resident was also ordered a chest x-ray on 05/11/23 that indicated possible fluid overload, however there was no documentation to support the order or assessment of the resident after receiving the x-ray results. ADON #120 revealed she did not believe Resident #67 had a change of condition on 05/12/23 or 05/13/23; however there was no documented evidence to support the resident's condition except a phone interview that was completed on 05/24/23 with LPN #151 and after the above concerns that had been identified by the State 366478 Page 19 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 survey agency. Level of Harm - Actual harm On 05/24/23 at 12:33 P.M. interview with Resident #67's family, Family Member #199 revealed she rode in the squad on 05/14/23 to the emergency room (ER) with Resident #67. The family member stated when the squad transferred Resident #67 to the bed in the emergency room the emergency room (ER) nurse looked at Resident #67's skin and reported the resident had a bad pressure ulcer on her buttocks. During this interview and a subsequent interview on 05/31/23 at 2:19 P.M. Family Member #199 reported she had visited the resident in the facility on 05/12/23. On 05/14/23 when visiting, the family member felt the resident was confused and lethargic and asked the nurse to assess the resident. The resident's blood pressure was low, and she had asked the nurse to transfer the resident to the emergency room. The facility nurse reported to her (Family Member #199) and the ambulance driver Resident 67's had been like this for three days and had not eaten or consumed fluids. Family Member #199 revealed the facility had reported to them the resident's weight was 113 pounds but in the emergency room, the family was told the resident weighed 85 pounds. The family member denied the resident or herself reporting the resident weighed 85 pounds to hospital staff. Family Member #199 reported the family didn't understand why the resident was on fluid restriction because she had not been on a fluid restriction or special diet when she was in the hospital (prior to the nursing home admission). The family member also indicated the resident would not eat the mechanically altered diet provided by the facility. After being treated in the hospital, the resident was discharged to a different skilled nursing facility in the area and had done a complete 180 degree turn around (improvement). Family Member #199 revealed she had shown co-workers pictures of the resident while she was at the facility compared to the current skilled nursing facility and they couldn't believe the improvement. The resident had gained weight and was able to use Facetime and communicate with family. The resident reported to family that facility staff never checked on her, which she felt was accurate as when family visited no staff ever came in to check on the resident. Residents Affected - Few On 05/24/23 at 1:16 P.M. interview with STNA #124, STNA #188, and LPN #153 with RRD #197 revealed the STNA staff reported they did not include fluids as part of their meal intake documentation. The LPN reported she only documented on the treatment administration record (TAR) the fluids nursing staff administered. The STNA and LPN confirmed they do not calculate or document the fluids dietary provided. RRD #197 reported she was not aware staff were not monitoring or documenting the fluids dietary was providing on the meal trays. She thought 25% of the meal intakes staff were recording under the task tab in the EMR include fluids provided at mealtime. The RRD reported all residents, no matter the diagnosis, should have fluid monitoring. Nutritional intakes were more important than solid intakes. During the interview, RRD #197 verified Resident #67 was not receiving adequate fluids while in the facility especially given the admitting diagnosis to the hospital on [DATE]. On 05/24/23 at 3:30 P.M. interview with the Administrator confirmed the RD had ordered a house supplement, 120 ml twice daily on 04/27/23, however the order was never implemented, and the resident did not receive the supplement. On 05/25/23 at 11:36 A.M. interview with COTA #203 revealed Resident #67 was more confused and lethargic (on 05/12/23) so she took the resident back to the nurse's station to report the change of condition to the nurse. COTA #203 stated the nurse thought the resident had a urinary tract infection (UTI). On 05/25/23 at 12:30 P.M. interview with Physical Therapist (PT) #204 revealed the resident was a skinny little thing. PT #204 revealed the resident spent most of her time in bed. 366478 Page 20 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Level of Harm - Actual harm Residents Affected - Few On 05/25/23 at 12:45 P.M. interview with STNA #114 revealed she provided care to Resident #67 during the resident's stay. STNA #114 revealed the resident was confused but could let you know her needs. The resident would ask for fluids; however, since she was on a fluid restriction the nurses would have to provide fluids to the resident. STNA #114 revealed STNA staff did not monitor or document resident fluids intakes. The STNA indicated the resident was a tiny bony lady and required encouragement to eat, drink, and even to get out of bed. During the resident's stay, the resident had dried skin on the top of her buttocks and complained it was sore. On 05/25/23 at 1:36 P.M. interview with Resident #67's primary care physician, who was also the facility medical director, Medical Director #196 revealed he was not aware of the nutritional concerns with Resident #67 including the failure to provide nutritional supplements, the lack of nutritional support with the resident being admitted to the facility with a pressure ulcer as well as developing a pressure ulcer during her stay, the resident's decreased meal intakes and fluid intakes, the facility not providing the resident the correct diet, the presence of thrush for several days before it was reported or the resident's condition change over the last few days of her stay until the time of this interview. The MD reported he was the only provider for the facility and staff should notify him immediately with weight changes if they were significant or not and even if they occur sooner than one month or six months as indicated by the dietician. Weight loss needed to be addressed sooner than when the loss became significant. The MD reported he could not change the concerns identified for Resident #67 but stated he would make arrangements to meet with the dietitian to discuss the concerns and begin a corrective action plan. The physician was unaware the facility did not have policies and procedures in place related to weights, weight loss and fluid intakes. On 05/25/23 at 3:28 P.M. interview with ADON #120 revealed in the facility paper weight book, if a resident's name was highlighted yellow that indicated the resident required weekly weights. The ADON revealed STNA staff were responsible to obtain the weights, however the STNA staff did not have access to record the weights in the electronic medical record (EMR) and would either document the weight on sticky note, scrap piece of paper, or a report sheet and then give it to the nurse working to chart the weight in the EMR. The papers (used by the STNAs to document the resident weights) were then shredded. On 05/25/23 at 3:09 P.M. interview with RN #136 revealed she could not remember what Resident #67's weights were as the STNA staff obtained the weights; however, she thought the resident's weights varied. The RN also noted STNA staff did not have access to the EMR to record the weights and the STNAs would give her weights usually documented on a sticky note and then she would document the weight in the EMR for the STNA. The RN confirmed she had documented Resident #67's weight on 05/11/23, however could not recall where she got the resident's weight to record in the EMR. On 05/25/23 at 3:12 P.M. interview with RD #198 confirmed the paper weight book did not have any documented weights for any residents residing on the 200, 300, 400 or 500 halls including Resident #67 for the week of 05/10/23. The RD confirmed she had documented in the EMR on 05/10/23 the resident weighed 112.5 pounds, however she was unable to recall where she got that weight from. RD #198 confirmed Resident #67 weights that were documented in the EMR on 05/10/23 and 05/11/23 were not documented in the paper weight book. The RD stated the paper weight book was for the RD to reference and the licensed nurse would document the weight in the paper weight book after notification was received from the STNA of the resident's weight. On 05/25/23 at 3:16 P.M. interview with STNA #161 revealed she did not recall what Resident #67's weights were, however she did recall weighing the resident using a weight chair and stated she 366478 Page 21 of 22 366478 06/08/2023 Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750

F 0692 Level of Harm - Actual harm Residents Affected - Few believed the resident was a weekly weight. The STNA confirmed she didn't have access to enter weights in the EMR and stated she usually documented the weights on a shift report sheet and gave the weights to the nurses to be documented in the EMR. During the interview STNA #161 revealed Resident #67 was on a mechanical soft diet and would try to feed herself. STNA #161 recalled the family wanted the resident's diet upgraded to a regular diet due to the resident's poor intake. The STNA stated the resident's family would bring drinks and food in for Resident #67 even though she was on a fluid restriction and a mechanical soft diet. On 05/30/23 at 12:37 P.M. and 1:24 P.M. interview with Hospital Coordinator #206, Hospit[TRUNCATED] 366478 Page 22 of 22