Health inspection·April 28, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff and resident interviews, and policy review, the facility failed to allow residents to make their own choices related to food options at meals. This affected five (#14, #28, #31, #40 and #45) of five residents interviewed and expressed concerns over the lack of food choices being offered. The census was 54. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 06/29/17, with diagnoses including: nutritional deficiency, chronic heart failure, and a history of COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Interview on 04/25/22 at 7:33 P.M.,with Resident #14 stated in the past, dietary aides came to the resident's rooms to offer meal options, but they no longer offered those options. Interview on 04/26/22 at 2:33 P.M., with Dietary Manager #747 verified dietary aides used to bring the menu of alternate options around to residents but due to the COVID-19 pandemic they stopped offering additional options. Interview on 04/28/22 at 10:00 A.M., with Residents #28, #31, and #45 during the Resident Council meeting stated they are not offered food choices with meals. 2. Review of the medical record for Resident #40 revealed an admission date of 06/05/12 and a readmission date of 04/18/22. Diagnoses included chronic obstructive pulmonary disease (COPD), cellulitis, acute respiratory failure, acute kidney failure, congestive heart failure, morbid obesity, hypertension, type II diabetes, anxiety disorder, major depressive disorder, post-traumatic stress disorder, hemiplegia and hemiparesis, and cerebral infarction (stroke). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Interview on 04/26/22 at 7:46 A.M., with Resident #40 revealed the facility did not ask about resident's food preferences for meals. Resident #40 denied the facility provided a menu and residents did not know what was being served until the meal arrived. Resident #40 denied alternative meal options were provided. Interview on 04/26/22 at 4:46 P.M., with the Director of Nursing (DON) revealed residents were Page 1 of 10 365279 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided a list of alternative menu items in a welcome packet during admission. The DON was unaware if the alternative menu was posted or provided to residents at any other time. Interview on 04/26/22 at 5:06 P.M., with [NAME] #656 revealed prior to COVID-19, staff would go room to room and ask residents for their meal selections. [NAME] #656 verified residents were not asked for their meal preferences and were served the main menu item. [NAME] #656 stated there was an alternative menu, which included hamburgers, meatloaf, salads, grilled cheese, and hot dogs. [NAME] #656 verified residents were provided the alternative menu list at admission but was not aware of it being posted or provided to residents at any other time. [NAME] #656 stated State Tested Nurse Aides (STNA) were supposed to let the kitchen staff know if a resident did not like what was served and an alternative menu item would be provided. [NAME] #656 verified this was dependent on residents knowing an alternative could be requested and STNA staff notifying the kitchen. Interview on 04/26/22 at 5:14 P.M., with STNA #540 revealed while alternative menu items were available, STNA #540 verified residents were not asked about their meal choices or preferences and alternatives were not offered unless a resident expressed they did not like the meal. Review of the undated policy titled Select Menus, revealed select menus will be provided to all individuals who choose to make their own menu selections. Assistance from family or staff is encouraged for those who cannot make their own choices. 365279 Page 2 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of the resident trust account balances, review of the surety bond, and staff interview, the facility failed to ensure the surety bond was sufficient to cover the total of resident trust accounts held at the facility. This affected 30 (#1, #3, #4, #6, #7, #8, #10, #13, #14, #16, #17, #18, #20, #21, #22, #23, #25, #28, #29, #30, #31, #35, #38, #40, #43, #44, #45, #48, and #49) of 30 residents identified by the facility as having a resident trust account. The facility census was 54. Residents Affected - Some Findings included: Review of the resident trust account balances, dated 04/25/22, revealed the total of resident trust accounts, including the assisted living facility, totaled $51,050.65. Thirty (#1, #3, #4, #6, #7, #8, #10, #13, #14, #16, #17, #18, #20, #21, #22, #23, #25, #28, #29, #30, #31, #35, #38, #40, #43, #44, #45, #48, and #49) facility residents were listed as having money in the resident trust account. Review of the surety bond, dated 06/16/20, revealed coverage in the amount of $50,000.00. Interview on 04/28/22 at 10:43 A.M., with the Business Office Manager (BOM) #550 verified the facility's surety bond, in the amount of $50,000.00, was not sufficient to cover the total of resident trust accounts, totaling $51,050.65. BOM #550 verified the surety bond covered both the nursing home and assisted living resident trust accounts. BOM #550 stated she needed to discuss increasing the surety bond with the Administrator. 365279 Page 3 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of a wheelchair cleaning schedule, the facility failed to ensure wheelchairs were maintained in a safe and comfortable manner. This affected one (#16) of three reviewed for environmental concerns. The facility identified 36 residents who utilized wheelchairs. The census was 54. Findings include: Review of Resident #16's medical record revealed an admission date of 05/09/19. Diagnoses included chronic obstructive pulmonary disease, acute kidney failure, rhabdomyolysis, congestive heart failure, and altered mental status. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was assessed with moderately impaired cognition. Observation on 04/25/22 at 8:37 P.M., revealed Resident #16 was laying awake in bed, with his wheelchair located at the foot of the bed. Further observation of the wheelchair revealed the right arm rest was torn with foam padding exposed and hanging out the front portion of the arm rest. Upon further inspection, the right arm rest was noted to only be anchored in the back portion and the arm rest was able to pivot off the metal post it was to be anchored to. Interview on 04/25/22 at 8:39 P.M., with Resident #16 stated the arm rest of the wheelchair had been like that for some time and referred to the wheelchair as junk. Observation on 04/26/22 at 11:35 A.M. and 2:44 P.M., revealed the right arm rest of Resident #16's wheelchair remained ripped and loose from the post. Resident #16 was not observed in his wheelchair on 04/26/22. Observation on 04/27/22 at 10:43 A.M., revealed Resident #16 was up sitting in his wheelchair in his bedroom. The right arm rest of the wheelchair was observed turned in a 180 degree fashion and was pointing directly backwards on the anchor post. Resident #16's right forearm was observed resting directly on the bare metal post of the wheelchair. Observation on 04/27/22 at 11:44 A.M., revealed Resident #16 remained sitting in his wheelchair with his right forearm resting on bare metal and the arm rest was turned completely backwards. Interview on 04/27/22 at 11:45 A.M., with Resident #16 stated it was uncomfortable for his arm to be resting on the bare metal and he could not find the arm rest which was turned completely backwards on the right side of the wheelchair. Interview on 04/27/22 at 11:52 A.M., with Licensed Practical Nurse (LPN) #644 verified the right arm rest on Resident #16's wheelchair was ripped, exposing foam padding, and was completely backwards on his wheelchair requiring Resident #16 to rest his right forearm on bare metal. Observation of Resident #16's right forearm at this time with LPN #644 revealed no skin tears, ulcers, or redness. Review of an undated form titled Wheelchair Cleaning Schedule revealed Resident #16 was scheduled to have his wheelchair cleaned every Wednesday and Saturday. 365279 Page 4 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0637 Assess the resident when there is a significant change in condition 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, staff interview, and review of facility policy, the facility failed to complete a significant change in status assessment. This affected one (#29) of 17 residents reviewed for assessments. The facility census was 54. Residents Affected - Few Findings included: Review of the medical record for Resident #29 revealed an admission date of 03/12/18 and a readmission date of 02/11/22. Diagnoses included metabolic encephalopathy, protein calorie malnutrition, acute kidney failure, acute cystitis with hematuria, atrial fibrillation, morbid obesity, personal history of COVID-19, major depressive disorder, brief psychotic disorder, hypertension, [NAME] fever, malignant neoplasm of left breast, and malignant neoplasm of right breast. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was moderately cognitively impaired and required extensive two person assistance with transfers, dressing, toilet use. Additional review revealed a significant change in condition assessment was initiated on 04/11/22. Review of a nursing progress note dated 04/05/22 at 6:33 P.M. revealed Resident #29 was admitted to hospice services. Review of a social services progress note dated 04/06/22 at 12:43 P.M. revealed Resident #29 had a significant change and was on hospice services. Interview on 04/27/22 at 1:45 P.M., of MDS Coordinator #601 verified a significant change in status assessment was initiated on 04/11/22 due to Resident #29 enrolling on hospice services. MDS Coordinator #601 verified the significant change in status assessment had not been completed. Review of facility policy titled Resident Assessments, revised November 2019, revealed a significant change in status assessment was completed within 14 days of the interdisciplinary team determining that the resident met the guidelines for major improvement or decline. In addition, a significant change in status assessment was required when a resident enrolled onto a hospice program. 365279 Page 5 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

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 medical record review, staff interview, and review of policy, the facility failed to revise resident's comprehensive care plans to accurately reflect services provided. This affected two (#29 and #26) of 17 residents reviewed for care plans. Findings included: 1. Review of the medical record for Resident #29 revealed an admission date of 03/12/18 and a readmission date of 02/11/22. Diagnoses included metabolic encephalopathy, protein calorie malnutrition, acute kidney failure, acute cystitis with hematuria, atrial fibrillation, morbid obesity, personal history of COVID-19, major depressive disorder, brief psychotic disorder, hypertension, [NAME] fever, malignant neoplasm of left breast, and malignant neoplasm of right breast. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was moderately cognitively impaired and required extensive two-person assistance with transfers, dressing, toilet use. Additional review revealed a significant change in condition assessment, dated 04/11/22, was in progress. Review of a nursing progress note dated 04/05/22 at 6:33 P.M., revealed Resident #29 was admitted to hospice services. Review of a social services progress note dated 04/06/22 at 12:43 P.M., revealed Resident #29 had a significant change and was on hospice services. Review of the plan of care, initiated 12/02/19, revealed no care planned interventions for hospice services. Interview on 04/27/22 at 1:45 P.M., with MDS Coordinator #601, revealed hospice services should be included in a resident's plan of care. MDS Coordinator #601 verified Resident #29's plan of care was not revised to include hospice services. 2. Review of the medical record for Resident #26 revealed an admission date of 11/23/21. Diagnoses included end stage renal disease, dependence on renal dialysis, type II diabetes, chronic obstructive pulmonary disease (COPD), major depressive disorder, heart disease, atrial fibrillation, osteoarthritis, muscle wasting and atrophy, muscle weakness, and personal history of transient ischemic attack and cerebral infarction (stroke). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and required extensive two person assistance with transfers, toilet use, and personal hygiene and extensive one person assistance with bed mobility and dressing. Review of the plan of care initiated 11/24/21 and revised 01/28/22, revealed Resident #26 required assistance with Activities of Daily Living (ADLs) related to weakness, shortness of breath, pain, and muscle wasting. Interventions did not address assistance needed with transfers, bed mobility, dressing, toilet use, or personal care. 365279 Page 6 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/26/22 at 2:38 P.M., with State Tested Nurse Aide (STNA) #525 revealed Resident #26 required extensive assistance with transfers, dressing, toilet use, and personal care. STNA #525 stated Resident #26 required the use of a mechanical list for transfers. STNA #525 stated resident care needs and level of needed assistance was included in the plan of care. Interview on 04/27/22 at 4:54 P.M., with the Director of Nursing (DON) revealed the plan of care should be developed based on the results of the MDS assessment. The DON verified Resident #26's plan of care did not reflect interventions related to needed assistance related to transfers, toilet use, dressing, and personal hygiene. Additionally, the DON stated this should have been completed by the previous MDS nurse and there was a reason why she was no longer the MDS nurse. Review of policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Additionally, the interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition. 365279 Page 7 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

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, medical record review, family and staff interviews, and review of policy, the facility failed to provide nail care to residents dependent for care. This affected one (#35) of 17 residents reviewed for activities of daily living. The facility census was 54. Residents Affected - Few Finidngs include: Review of the medical record for Resident #35 revealed an admission date of 12/17/15. Diagnoses included dementia, heart failure, acute respiratory failure, chronic obstructive pulmonary disease (COPD), kidney disease, schizoaffective disorder, heart disease, anxiety disorder, bipolar disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #35 was moderately cognitively impaired and required extensive assistance with personal hygiene. Review of the plan of care, initiated 12/24/15, revealed Resident #35 required supervision up to extensive assistance, with activities of daily living (ADLs) related to depression, muscle weakness, dementia, anxiety, altered though process at times due to schizophrenia and bipolar disorder. Interventions included keep resident's nails clean and cut. Observation on 04/26/22 at 8:13 A.M., with Resident #35 revealed the Resident's fingernails were approximately 1/4 to 1/2 inch long, jagged, and had a black substance under the nails. Interview on 04/26/22 at 11:52 A.M., with Resident #35's family member revealed the only concern related to Resident #35's care was her nails were sometimes too long and dirty. The family member stated Resident #35 always kept her fingernails short. Interview on 04/27/22 at 7:55 A.M., with Licensed Practical Nurse (LPN) #619 verified Resident #35's fingernails were nails long, jagged, and dirty. LPN #619 stated activities staff generally provided nail care. LPN #619 was uncertain when the Resident last received nail care. Interview on 04/27/22 at 10:36 A.M., with Activities Director (AD) #680 revealed activities staff generally provide nail care and document in the Electronic Medical Record (EMR) when care was provided. AD #680 was unsure when Resident #35 last received nail care, stated she would have to check her records, and asked if Resident #35 needed nail care. Follow-up interview on 04/27/22 at 11:10 A.M., with AD #680 verified activities did not have any documentation of nail care provided to Resident #35. AD #680 stated she spoke with State Tested Nurse Aide (STNA) #600 who told her she provided nail care to Resident #35 last week. Interview on 04/27/22 at 11:15 A.M., with STNA #610 revealed she clipped Resident #35's fingernails last week. STNA #610 stated Resident #35 drinks several glasses of milk each day and that must help make the Resident's nails grow. STNA #610 stated Resident #35 preferred her nails long. Review of the policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 365279 Page 8 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and review of facility policies, the facility failed to manage soiled and clean linen to potentially prevent cross-contamination. This had the potential to affect 54 of 54 residents who utilized laundry services at the facility. The facility census was 54. Residents Affected - Many Findings included: Observation on 04/27/22 at 7:35 A.M., of the laundry area revealed laundry was located in the basement of the facility. There was one room for folding and hanging clean linen and a separate room where the washers and dryers were located. Interview on 04/27/22 at 7:38 A.M., of Housekeeper (HK) #581 revealed all laundry was transported down the stairway to the laundry rooms. Soiled linens were placed into the washers, dried, and then transported into a separate room to be folded. HK #581 stated since the facility did not have an elevator, staff had to carry armfuls of clean linen up the stairs to place on carts for delivery to resident care areas. Observation on 04/27/22 at 8:36 A.M., of laundry delivery revealed HK #725 pick up a stack of clean towels and hold them against her clothing and body. Interview at the time of the observation of HK #725 verified she picked up clean linen and held it against her body and clothing to carry it up the stairs from the basement of the facility. Continued interview of HK #725 and HK #581 revealed both worked in the laundry department. HK #725 and HK #581 verified laundry staff did not wear any protective barriers, such as a gown, when sorting and washing soiled laundry. Additionally, both HK #725 and #581 verified they did not wear any protective barrier when holding clean linens against their body while transporting the linen up the stairs for delivery to resident care areas. HKs #725 and #581 each stated they were unaware they should keep linens away from their body or wear a protective barrier when laundering soiled linens. Interview on 04/27/22 at 8:41 A.M., of Housekeeping Supervisor (HS) #736 verified staff did not wear a protective barrier, such as a gown, when doing laundry. HS #736 verified staff carried clean linen up the stairs from the basement and clean linen would be held against the staff's body. HS #736 stated she had never heard linen should be not be held against the body or a protective barrier should be worn when laundering soiled linens to prevent contamination of clean linen. While there was a supply of gowns in the laundry area, HS #736 stated she would ensure a sufficient supply was available for staff. Interview on 04/27/22 at 1:08 P.M., of Infection Preventionist (IP) #510 revealed facility staff received annual infection control training to prevent potential infection control concerns. IP #510 revealed all facility staff, including housekeeping and laundry, attended infection control trainings, which included the handling of linen. Review of policy titled Departmental (Environmental Services) - Laundry and Linen, revised January 2014, revealed staff sorting or washing linen must wear a gown and gloves, clean linen would remain hygienically clean through measures designed to protect it from environmental contamination, and barrier attire should be removed when leaving the soiled linen area. Review of policy titled Laundry and Bedding, Soiled, revised October 2018, revealed soiled laundry and bedding shall be handled, transported and processed according to best practices for infection 365279 Page 9 of 10 365279 04/28/2022 Merit House LLC 4645 Lewis Ave Toledo, OH 43612

F 0880 prevention and control. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 365279 Page 10 of 10