Health inspection·July 22, 2021

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to complete a residents discharge summary. This one (#41) of one resident reviewed for closed medical discharge records. The facility census was 47. Findings include: Review of the closed medical record for Resident #41 revealed an admission date of 05/25/21 and a discharge date of 06/14/21. Diagnoses included cerebral infarction, hypertension, benign prostatic hyperplasia, gastroesophageal reflux disease, major depression, speech and language deficits, muscle weakness, difficulty walking, dysphagia and cognitive communication. Review of the five day admission Minimum Data Set (MDS) dated [DATE] revealed a Resident #41 had a Brief Interview for Mental Status (BIMS) of 04 indicating severe cognitive impairment. Review of Resident #41's progress note dated 06/14/21, revealed Resident #41 was discharged from the facility to another facility. Further review of Resident #41's medical record revealed no evidence or documentation of a discharge summary being completed. Interview with the Administrator on 07/21/21 at 4:00 P.M., confirmed a discharge summary for Resident #41 was not completed. Review of facility policy, Discharge Summary and Plan with a revision date of 12/2016 revealed when the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/ICD, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. Page 1 of 4 365232 365232 07/22/2021 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

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 medical record review, observations, staff interview and review of facility policy, the facility failed to assist a resident with changing his clothes. This affected one (#7) out of four residents reviewed for Activities of Daily Living (ADL's). The facility's census was 47. Residents Affected - Few Findings included: Medical record review for Resident #7 revealed an admission date of 12/09/16. Diagnoses included, Alzheimer's, major depressive disorder, dementia, insomnia, psychosis, acute kidney failure, dysphagia, and high blood pressure. Review of Resident #7's Minimum Data Set 3.0 Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #7 had moderate cognitive impairment. Resident #7 required limited assistance from one staff person with dressing. There were no behaviors documented, including no indication Resident #7 refused care or assistance from staff. Review of Resident #7's care plan with a date initiated of 10/16/19 revealed Resident #7 had an ADL deficit related to dementia and required limited assistance from one staff person with dressing. Further review revealed Resident #7 had a knowledge deficit related to dementia and was to be encouraged to participate in ADL's and staff were to assist as needed. Observations on 07/19/21 at 11:14 A.M., 1:34 P.M., and 3:51 P.M. revealed Resident #7 was wearing khaki pants with a red long-sleeved shirt. Observations on 07/20/21 at 9:43 A.M. and 2:44 P.M. Resident #7 was observed wearing the same khaki pants and red long-sleeved shirt observed on 07/19/21. At 2:44 P.M. the shirt and pants were soiled with stains. The shirt had white stains and the pants had a few dark wet spots and a neon orange spot. Observations on 07/21/21 at 9:14 A.M. and 1:33 P.M. Resident #7 was observed wearing the same khaki pants and red-long sleeved shirt observed on 07/19/21 and 07/20/21. The pants and shirt continued to be soiled with the same stains observed on 07/20/21 at 2:44 P.M. Interview on 07/21/21 at 1:33 P.M. State Tested Nurse Aide (STNA) #270 reported Resident #7 was compliant with care and accepting of assistance from staff. STNA #270 verified Resident #7 was wearing the same clothes two days in a row (07/20/21 and 07/21/21). STNA #270 was observed offering Resident #7 assistance with picking out new clothes to wear and offered assistance with dressing. Resident #7 actively engaged in picking out his clothes and was agreeable to changing his clothing. Interview on 07/21/21 at 1:35 P.M. Licensed Practical Nurse (LPN) #181 verified Resident #7 was compliant with care and allowed staff to assist with care. LPN #181 verified Resident #7 would need assistance and/or prompting from staff for dressing/changing clothes. Interview on 07/21/21 at 1:50 P.M. LPN #181 verified Resident #7's care plan stated Resident #7 required limited assistance from one staff person with dressing. Observation on 07/21/21 at 2:09 P.M. Resident #7 was observed wearing a different outfit of black 365232 Page 2 of 4 365232 07/22/2021 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

F 0677 pants and a gray long-sleeved shirt. Level of Harm - Minimal harm or potential for actual harm Review of facility undated policy titled, Activities of Daily Living (ADL's)/Maintain Abilities, revealed the facility would ensure residents were given the appropriate treatment and services, including dressing. Residents Affected - Few 365232 Page 3 of 4 365232 07/22/2021 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

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 medical record review, observation, resident and staff interviews and review of facility policy, the facility failed to ensure a resident had access to her call light to potentially prevent an accident or fall. This affected one (#13) out of three residents reviewed for fall management. The facility's census was 47. Findings included: Medical record review for Resident #13 revealed an admission date of 04/01/21. Diagnoses included, nontraumatic subacute subdural hemorrhage, unspecified fall, atherosclerotic heart disease, contusion of front wall of thorax, other seizures, transient cerebral ischemic attack, muscle weakness, chronic obstructive pulmonary disease, heart failure, anemia, scoliosis, osteoarthritis, stage IV kidney disease, and high blood pressure. Review of Resident #13's Minimum Data Set 3.0 Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #13 was cognitively intact. Resident #13 required limited assistance with bed mobility, transfers, walking, eating, toileting, and maintaining hygiene and extensive assistance with dressing. Resident #13 had suffered from a fall since admission. Review of Resident #13's care plan with a date initiated of 01/19/21, revealed Resident #13 was at risk for falls with interventions in place to encourage use of call light for assistance and to keep the call light within reach. Observation on 07/21/21 at 1:25 P.M. Resident #13 was observed seated in her recliner chair covered with a blanket. Her call light was observed clipped onto her bed, in-between the side rails. Resident #13 attempted to reach her call light and was unable to do so. Resident #13 verified she was unable to reach her call light. Staff interviews on 07/21/21/ at 1:26 P.M. Licensed Practical Nurse (LPN) #181 and State-Tested Nurse Aide (STNA) #270 verified Resident #13 did not have access to her call light. STNA #270 added she felt therapy staff forgot to provide her call light to her. LPN #181 removed the call light from the bed and clipped it within reach of Resident #13. Review of facility policy titled, Falls- Clinical Protocol, revealed interventions to prevent palls would be identified and utilized. 365232 Page 4 of 4