Health inspection·May 2, 2024

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility did not ensure Resident Fund Authorizations were witnessed. This affected six of six residents (#41, #63, #76, #83, and #220) whose fund accounts were reviewed. The facility census was 120. Residents Affected - Some Findings include: Review of the authorization forms for Resident Fund Accounts for six residents (#41, #63, #76, #83, and #220) revealed none had been witnessed as required. Interview on 04/30/24 at 3:38 P.M. Business Office Manager #506 verified the facility had not had the Resident Fund Account authorization forms witnessed. Page 1 of 42 365290 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on interview, record review and facility policy review, the facility failed to implement policy and procedure for the prevention of abuse by not completing job reference checks and documenting timely state nurse aide registry (NAR) checks for new employees. This had the potential affect all 120 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #516 revealed a hire date of 06/13/23. There was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Receptionist #597 revealed a hire date of 06/27/23. The printed evidence of Receptionist #597 being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Registered Nurse (RN) #600 revealed a hire date of 07/11/23. The printed evidence of RN #600 being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Maintenance Director (MD) #594 revealed a hire date of 10/04/23. The printed evidence of MD #594 being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Director of Nursing (DON) revealed a hire date of 10/17/23. The printed evidence of DON being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Unit Manager Licensed Practical Nurse (LPN) #591 revealed a hire date of 11/14/23. The printed evidence of LPN #591 being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. Review of the personnel file for LPN #571 revealed a hire date of 11/21/23. There was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Human Resource Business Partner (HRBP) #560 revealed a hire date of 03/05/24. The printed evidence of HRBP #560 being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. Review of the personnel file for Assistant Director of Nursing (ADON) #504 revealed a hire date of 04/03/24. The printed evidence of ADON #504 being checked against the NAR was not dated. There was no evidence the NAR check was timely, and there was no evidence in the personnel file of completed job reference checks. 365290 Page 2 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0607 Level of Harm - Potential for minimal harm Review of the personnel file for STNA #513 revealed a hire date of 04/03/24. There was no evidence in the personnel file of completed job reference checks. Review of the personnel file for STNA #514 revealed a hire date of 04/17/24. There was no evidence in the personnel file of completed job reference checks. Residents Affected - Many Interview on 05/01/24 at 12:17 P.M. with HRBP #560 verified the above findings were accurate. Review of the facility policy, Freedom from Abuse and Neglect Policy, undated, revealed pre-employment screening will be completed on all employees to include reference checks from previous employers and a registry check as applicable. The facility will not retain any employee with a history of abuse or neglect if that information was known to the facility. 365290 Page 3 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument User's Manual, the facility failed to ensure assessments were completed accurately for Residents #3, #8, #9, #14, #15, #20, #33, #36, #37, #39, #40, #48, #52, #53, #55, #62, #65, #68, #73, #76, #78, #80, #82, #85, #88, #91, #93, #95, #97, #98, #99, #103, #104, #105, #107, #108, #112, #114, #317, #319 and #1070. This affected 41 residents (#3, #8, #9, #14, #15, #20, #33, #36, #37, #39, #40, #48, #52, #53, #55, #62, #65, #68, #73, #76, #78, #80, #82, #85, #88, #91, #93, #95, #97, #98, #99, #103, #104, #105, #107, #108, #112, #114, #317, #319 and #1070) of 42 residents reviewed for resident assessments. The facility census was 102. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of dementia with behaviors, Alzheimer's disease, high blood pressure, legal blindness, schizophrenia, and a stroke. Review of the physician's orders for Resident #62 revealed she was admitted to hospice services on 09/18/22 for vascular dementia with cerebral vascular disease. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was severely cognitively impaired and was rarely understood. She demonstrated physical behaviors towards others, verbal behaviors directed at others and rejected care one to three days of the assessment. The Section J, Health Conditions, part of the assessment revealed the resident does have a life expectancy of less than six months. Section O, Special Treatments, was marked as not receiving hospice services. Review of the care plans for Resident #62 revealed a hospice service care plan for vascular dementia, cerebral vascular disease was initiated on 09/20/22. Interview with MDS Director #596 on 04/24/24 at 11:21 confirmed she had incorrectly coded the quarterly MDS assessment dated [DATE]. Section O, Special Treatment. should have been coded as receiving hospice services. 2. Review of the medical record revealed Resident #114 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Admitting diagnoses included hypotension, a pacemaker, a left pubis fracture, epilepsy, chronic obstructive pulmonary disease, heart disease, alcohol abuse, and cannabis abuse. Review of the comprehensive quarterly MDS 3.0 assessment dated [DATE] revealed Resident #114 was cognitively intact and was independent for self-care. Review of the discharge plan for Resident #114 dated 02/02/24 revealed discharge was initiated by the resident, and he was planning on moving out of state to be with a friend. The facility made a referral for housing as well as for a waiver for an assisted living facility. Review of the progress notes for Resident #114 revealed on 02/02/24 the resident was discharged home with his sister. On 02/07/24 Social Services Director (SSD) #606 spoke with Resident #114 who told 365290 Page 4 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0641 her he had made it safely to his friend's state and was very happy there. Level of Harm - Minimal harm or potential for actual harm Review of the discharge MDS 3.0 assessment for Resident #114 dated 02/02/24 revealed the discharge was planned, and the resident was discharged to a short-term general hospital. Residents Affected - Some Interview with MDS Director #596 on 04/24/24 at 11:21 A.M. confirmed she completed the discharge MDS assessment for Resident #114, and she should have selected the discharge, return not anticipated answer. 3. Review of the medical record for Resident #37 revealed an admission date of 12/05/23. Diagnoses included need for assistance with personal care, protein-calorie malnutrition, congestive heart failure, and type II diabetes mellitus. Review of the oral health evaluation dated 12/06/23 revealed Resident #37 had natural teeth with no identified concerns. Under the denture sections, missing or not worn was indicated. There were no additional notes or comments on the evaluation. The oral evaluation indicated it was completed by MDS Director #596. Review of the admission MDS assessment dated [DATE] revealed Resident #37 had impaired cognition and had no identified concerns related to her oral and dental status. Interview on 04/22/24 at 3:14 P.M., Resident #37 stated she had missing teeth and about three weeks ago lost her upper dentures. Resident #37 stated she reported them missing, staff looked for them, and they were unable to be located. Resident #37 stated she was to see the dentist early May 2024 Follow-up interview on 04/29/24 9:19 A.M., Resident #37 stated the dentist was to come in this week. Resident #37 stated she came to the facility with full top dentures and had no natural teeth on the top and a few natural teeth on the bottom. Resident #37 then opened her mouth and observed no upper teeth and lower missing teeth. Interviews on 04/29/24 at 9:24 A.M. and at 10:43 A.M. with MDS Director #596 stated when they obtain their information from staff and also interview with the residents. She did not complete the oral evaluation dated 12/06/23 but she closed it on 02/09/24. Someone else had to complete and it should have indicated partials and there was also a section for notes that staff could have added notes. Interview on 04/29/24 at 11:24 A.M. with the Director of Nursing (DON) stated she did not recall if Resident #37 came in with dentures, but the oral evaluation dated 12/06/23 was not accurately assessed. 4. Review of the medical record for Resident #3 revealed an admission date of 05/09/14. Diagnoses included Alzheimer's disease and major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #8 revealed an admission date of 05/03/23. Diagnoses included Alzheimer's disease and dementia. The Annual MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #9 revealed an admission date of 03/08/22. Diagnoses 365290 Page 5 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #14 revealed an admission date of 07/30/19. Diagnoses included dementia and major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #15 revealed an admission date of 07/19/22. Diagnoses included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #20 revealed an admission date of 02/11/22. Diagnoses included dementia, bipolar disorder, and major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #33 revealed an admission date of 02/10/22. Diagnoses included dementia, delusional disorder, and major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #36 revealed an admission date of 01/11/23. Diagnoses included dementia, schizophrenia, and bipolar disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #39 revealed an admission date of 02/16/22. Diagnoses included dementia and major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #40 revealed an admission date of 03/27/23. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #48 revealed an admission date of 05/11/23. Diagnoses included dementia and Alzheimer's disease. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #52 revealed an admission date of 02/18/23. Diagnoses included dementia and Alzheimer's disease. The Annual MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #53 revealed an admission date of 12/20/22. Diagnoses included dementia and Alzheimer's disease. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. 365290 Page 6 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the medical record for Resident #55 revealed an admission date of 04/03/23. Diagnoses included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #65 revealed an admission date of 11/18/19. Diagnoses included dementia and major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #68 revealed an admission date of 07/28/22. Diagnosis included major depressive disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #73 revealed an admission date of 04/04/24. Diagnoses included dementia and major depressive disorder. The admission MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #76 revealed an admission date of 04/14/23. Diagnoses included dementia. The Annual MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #78 revealed an admission date of 09/19/22. Diagnoses included dementia and hallucinations. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #80 revealed an admission date of 01/13/23. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #82 revealed an admission date of 01/13/23. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #85 revealed an admission date of 06/23/21. Diagnoses included dementia and delusional disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #88 revealed an admission date of 12/20/22. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #91 revealed an admission date of 11/17/21. Diagnosis included Alzheimer's disease. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #93 revealed an admission date of 10/06/22. Diagnoses included dementia and Alzheimer's disease. The Annual MDS 3.0 assessment dated [DATE], section P0200(F) 365290 Page 7 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0641 for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Level of Harm - Minimal harm or potential for actual harm Review of the medical record for Resident #95 revealed an admission date of 03/02/24. Diagnosis included dementia. The admission MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Residents Affected - Some Review of the medical record for Resident #97 revealed an admission date of 09/26/22. Diagnoses included dementia and Alzheimer's disease. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #98 revealed an admission date of 01/29/24. Diagnoses included dementia, bipolar disorder, and schizoaffective disorder. The admission and Medicare 5-day MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #99 revealed an admission date of 05/15/23. Diagnosis included vascular dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #103 revealed an admission date of 08/28/23. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #104 revealed an admission date of 11/03/23. Diagnoses included dementia and bipolar disorder. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #105 revealed an admission date of 10/10/23. Diagnosis included dementia. The Significant Change MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #107 revealed an admission date of 10/31/23. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #108 revealed an admission date of 03/01/24. Diagnosis included dementia. The admission MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #112 revealed an admission date of 04/01/24. Diagnoses included nontraumatic intracranial hemorrhage, and major depressive disorder. The admission MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Review of the medical record for Resident #317 revealed an admission date of 04/09/24. Diagnoses included schizoaffective disorder bipolar type. The admission MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of 365290 Page 8 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0641 alarm use. Level of Harm - Minimal harm or potential for actual harm Review of the medical record for Resident #319 revealed an admission date of 09/08/23. Diagnoses included dementia and Alzheimer's disease. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Residents Affected - Some Review of the medical record for Resident #1070 revealed an admission date of 09/08/23. Diagnosis included dementia. The Quarterly MDS 3.0 assessment dated [DATE], section P0200(F) for other alarms was coded as used daily. There was no evidence in the medical record of alarm use. Observation on 04/22/24 at 2:01 P.M. revealed all the above residents resided on the memory care unit. There were two entrance and exit doors, one led to the front lobby and out to the facility parking lot, and the other led to an annex hallway which joined the memory care building to the main facility building. Both doors had alarms and required a numerical code to silence the alarm when used. There were no residents in the memory care unit who had audible alarms. Interview on 04/22/24 at 2:33 P.M. with MDS Coordinators #595 and #596 verified all residents who resided in the memory care unit were coded in the MDS assessment section P0200(F) for other alarms used daily because of the alarmed entrance and exit doors. Review of the MDS 3.0 Resident Assessment Instrument User's Manual, dated October 2023, page P-11 revealed other alarms include devices such as alarms on resident bathrooms, bedroom door, toilet seat alarms or seatbelt alarms. Do not code a universal building exit alarm applied to an exit door that is intended to alert staff when anyone (including visitors or staff members) exits the door. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. 365290 Page 9 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission. This affected four residents (#105, #114, #418, and #419) of 32 residents reviewed for care plans. The facility census was 120. Findings include: 1. Resident #105 was admitted to the facility on [DATE] with diagnoses including dementia with severe agitation, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, diabetes, traumatic brain injury, and an abdominal aortic aneurysm. Review of the medical record for Resident #105 revealed no information regarding the resident or his responsible party being provided information regarding his care plan within 48 hours of admission. Review of the admission assessment for Resident #105 dated 10/10/23 revealed no information regarding formulation of a care plan for the resident. Interview with Minimum Data Set (MDS) Director #596 on 04/29/24 at 10:44 A.M. revealed whoever completes the admission assessment is the one who signs off on giving the resident a summary of the baseline care plan. MDS Director #596 confirmed she does not provide the resident or the responsible party with a copy of the baseline care plan. The baseline care plan she completes is directly entered into the care plan section of the electronic record. 2. Resident #114 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Admitting diagnoses included hypotension, a pacemaker, a left pubis fracture, epilepsy, chronic obstructive pulmonary disease, heart disease, alcohol abuse, and cannabis abuse. Review of the medical record for Resident #114 revealed no information regarding the resident or his responsible party being provided information regarding his care plan within 48 hours of admission. Interview with MDS Director #596 on 04/29/24 at 10:44 A.M. confirmed she created the baseline care plan for Resident #114, but she did not provide a summary of the baseline care plan to the resident. 3.Resident #418 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, atrial fibrillation, high blood pressure, and urinary retention. Review of the medical record for Resident #418 revealed no information regarding the resident or his responsible party being provided information regarding his care plan within 48 hours of admission. Interview with MDS Director #596 on 04/29/24 at 10:44 A.M. confirmed she created the baseline care plan for Resident #418, but she did not provide a summary of the baseline care plan to the resident. 4.Resident #419 was admitted to the facility on [DATE] with diagnoses including stroke, atrial fibrillation, congestive heart failure, chronic kidney disease dependent on dialysis, heart disease, dementia without behavioral disturbance, multiple myeloma, and diabetes. 365290 Page 10 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0655 Level of Harm - Minimal harm or potential for actual harm Review of the medical record for Resident #419 revealed no information regarding the resident or his responsible party being provided information regarding his care plan within 48 hours of admission. Interview with MDS Director #596 on 04/29/24 at 10:44 A.M. confirmed she created the baseline care plan for Resident #419, but she did not provide a summary of the baseline care plan to the resident. Residents Affected - Some Review of the facility's Baseline Care Plan policy, last revised March 2022, revealed a baseline care plan to meet the resident's immediate health and safety needs is to be developed for each resident within 48 hours of admission. The resident and/or their responsible party will be provided with a written summary of the baseline care plan and then that should be documented in the resident's electronic record. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. 365290 Page 11 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

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 interview, record review and facility policy review, the facility failed to formulate comprehensive care plans to include all necessary goals of care for Residents #21, #37 and #104. This affected three residents (#21, #37 and #104) of 29 residents reviewed for comprehensive care plans. The facility census was 120. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 03/28/24. Diagnoses included anxiety disorder, depression, type II diabetes mellitus, borderline personality disorder, bipolar disorder, schizoaffective disorder, and post-traumatic stress disorder (PTSD). Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had an intact cognition and PTSD listed as a diagnosis. There was no care plan in the medical record related to diagnoses of PTSD. Interviews on 04/29/24 at 9:24 A.M. and at 10:43 A.M. with MDS Director #596 stated they obtained their information from staff and interview with the residents. MDS Director #596 verified there was no care plan initiated for Resident #21's diagnosis of PTSD. 2. Review of the medical record for Resident #37 revealed an admission date of 12/05/23. Diagnoses included need for assistance with personal care, protein-calorie malnutrition, congestive heart failure, and type II diabetes mellitus. Review of the oral health evaluation dated 12/06/23 revealed Resident #37 had natural with no identified concerns. Under the denture sections, missing or not worn was indicated. There were no additional notes or comments on the evaluation. The oral evaluation indicated it was completed by MDS Director #596. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #37 had impaired cognition and had no identified concerns related to her oral and dental status. There was no care plan in the medical record related to Resident #37's oral/dental status. Interview on 04/22/24 at 3:14 P.M., Resident #37 stated she had missing teeth, and about three weeks ago, she lost her upper dentures. Resident #37 stated she reported them missing, staff looked for them, and they were unable to be located. Resident #37 stated she was to see the dentist early May 2024 Follow-up interview on 04/29/24 9:19 A.M., Resident #37 stated the dentist was to come in this week. Resident #37 stated she came to the facility with full top dentures and had no natural teeth on the top and a few natural teeth on the bottom. Resident #37 then opened her mouth and observed no upper teeth and lower missing teeth. Interviews on 04/29/24 at 9:24 A.M. and at 10:43 A.M. with MDS Director #596 stated they obtained their information from staff and interview with the residents. She did not complete the oral 365290 Page 12 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evaluation dated 12/06/23, but she closed it on 02/09/24. Someone else had to complete it, and it should have indicated partials. There was also a section for notes that staff could have added notes. She verified there was no care plan initiated for Resident #37's oral/dental status. 3. Review of the medical record for Resident #104 revealed an admission date of 11/03/23 with diagnoses including dementia with psychotic disturbance, aphasia (inability to understand and express language), restlessness and agitation, psychotic disorder with delusions, anxiety, and bipolar disorder. Review of the nursing progress note dated 11/07/23 revealed Resident #104's family reported Resident #104 wore contacts but had not utilized them since the hospital admission about one month prior and had a history of refusing contacts. Resident #104's family was advised the facility offered house eye exams and eye glass services if needed in the future. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had severe cognitive impairment with no use of corrective lenses. Review of the nurse practitioner progress note dated 11/27/23 indicated Resident #104 was examined with no concerns related to the eyes. The note indicated a contact lens remained within the right eye. Review of Resident #104's plan of care initiated 11/06/23 revealed no focus on eye care or the care of contact lenses. There was a focus on behavior which indicated Resident #104 refused taking her contacts out for regular washing. Interventions included to educate on non-compliance with treatment or care and reapproach with resistance to activities of daily. Review of the eye physician's progress note date 12/04/23 revealed Resident #104 was examined and had an air optic color contact lens in the right eye which was removed on this date. Staff were instructed to not let Resident #104 wear contact lenses. Resident #104 was scheduled to return for a follow-up in 12 to 15 months or in six to nine months for a retina evaluation. Review of the nursing progress note dated 01/15/24 indicated Resident #104 placed a contact lens into the right eye. Staff made several attempts to remove the contact lens but Resident #104 continued to refuse. Review of a social service progress note dated 01/25/24 revealed Resident #104's family decided to allow Resident #104 to wear contact lenses despite education on the risks of leaving contact lenses in place for lengthy time periods and not removing for routine washing. Nursing staff were made aware. Interview on 04/22/24 at 6:37 P.M. with Resident #104's family revealed a concern Resident #104 had a blue contact lens in the right eye which had been left in place for almost one year. The family member stated it was noticeable because the resident's left eye was green, her natural color, and the right eye was blue, the color of the contact lens. The family indicated staff explained they could not get it out, but stated the eye looked swollen now and it was concerning because the contact lens had been in for too long. Resident #104's family stated the contact lenses were brought in a while back but could not state a time frame. Interview on 04/24/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #584 verified Resident #104 365290 Page 13 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had used a contact lens since admission and currently only had one contact lens in the right eye which had been there for a while. Interview on 04/24/24 at 9:02 A.M. with Unit Manager LPN #607 verified Resident #104 had a right eye contact lens in place. LPN #607 revealed Resident #104 was admitted with a contact lens in the right eye. Resident #104 was encouraged to remove the contact lens but refused. The eye doctor had come to the facility and removed it. Social services told the family that due to Resident #104's dementia; it was not best to wear contacts and it was agreed but additional contact lenses were brought in which resulted in Resident #104 placing another contact lens in the right eye. There was never a contact lens in the left eye. Resident #104 would not allow staff to remove it or touch the eye. The family was asked to assist in getting the contact lens out, but they had not. Interview on 04/25/24 at 2:18 P.M. with MDS Directors #595 and #596 verified there was no care planning completed with a focus on eye care or the care of contact lenses for Resident #104 after admission. There was only a focus on behavior due to refusing to remove the contact lenses. An additional review of Resident #104's plan of care (initiated 11/06/23), revealed a new focus area was added on 04/25/24 (following surveyor intervention) for the resident's risk of injury related to infection due to use of contact lenses and refusing to allow staff to assist with inserting and removing. Interventions included administer antibiotic as ordered; apply warm compress as ordered; arrange eye care practitioner consult as required; document all refusals to allow staff to assist with contact lens; family would assist with placement and cleaning of contact lenses; keep spouse informed of refusal of assistance with contacts; monitor for, document and report as needed any signs and symptoms of acute eye problems; and per ophthalmology appointment on 12/04/23 Resident #104 not to wear contacts. Review of the facility policy, Comprehensive Care Plan, revealed the comprehensive care planning would include services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and any services required but not provided due to a resident's right to refuse treatment. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. 365290 Page 14 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to revise Resident #62's care plan in a timely manner. This affected one resident (#62) of 32 residents reviewed for care plans. The facility census was 120. Findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses of dementia with behaviors, Alzheimer's disease, high blood pressure, legal blindness, schizophrenia, and a stroke. Review of the physician's orders for Resident #62 revealed she was admitted to hospice services on 09/18/22 for vascular dementia with cerebral vascular disease. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was severely cognitively impaired and was rarely understood. She demonstrated physical behaviors towards others, verbal behaviors directed at others, and rejected care one to three days of the assessment reference period. The resident was dependent on staff for all care. Review of the progress notes revealed on 03/12/24 her restorative program for upper and lower range of motion exercises was discontinued due to the resident no longer being able to actively participate in the program. Review of the care plans for Resident #62 revealed a plan of care for a restorative program for active assist range of motion to maintain functional range of motion to bilateral lower extremities was initiated on 02/21/24. The facility discontinued the program on 03/12/24 due to the resident being unable to actively participate. The restorative program remained on the care plan as of 04/22/24 when the survey process began. Interview with MDS Director #596 on 04/24/24 at 11:21 A.M. confirmed she did not revise the care plan when the restorative range of motion for Resident #62 was discontinued. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. 365290 Page 15 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the activity log, activity evaluation, and review of the facility policy and procedure, the facility failed to ensure activities were provided consistently according to the care plan and resident preferences for Resident #70. This affected one resident (#70) of three residents reviewed for activities. The facility census was 120. Residents Affected - Few Findings include: Review of the medical record for Resident #70 revealed an admission date of 04/28/23. Diagnoses included dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, muscle weakness, and schizophrenia. Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. The assessment also indicated under activities it was very important to listen to music he likes, be around animals, to do things with groups of people, to do favorite activities, go outside for fresh air when the weather is good, and participate in religious services. The primary respondent was from family or significant other. Review of the plan of care dated 11/09/23 revealed Resident #70 required assistance with all mobility and activities of daily living. Interventions included activities such as enjoys cars (model cars), animals (pictures or videos), will name objects and engage with yes/no simple questions/answers to stimulate language; offer me things I can use independently such as coloring, magazines, puzzle books; please assist me to and from activity area as I am unable to do so myself; and please remind me of activities that I may enjoy such as music and parties. Review of activities quarterly review dated 02/02/24 listed under attendance and participation summary, indicated Resident #70 would attend large group activities one to two times weekly and was a passive observer. List for independent activities included individual activities such as daily walking, television (tv), music, people watching, socializing, weekly visits from family/friends, and sits daily with peers in the tv and dining room. The review also listed for Resident #70's favorite activities included for cognitive activities: news, trivia, and passive; entertainment activities: tv, music, and musical entertainment; and spiritual activities included enjoys church services. Review of activity calendar for April 2024 revealed church services every Wednesday at 10:30 A.M. dated 04/03/24, 04/10/24, 04/17/24, 04/24/24. Noted hymn singing on 04/05/24, 04/12/24, 04/19/24, and 04/26/24; 04/14/24 sentimental sing along; and every day at 12:00 P.M was music for lunch/dining. Reviewed activity logs for Resident #70 for April 2024 revealed he attended two group activities on 04/22/24 and 04/25/24: four - one on ones on 04/01/24, 04/02/24, 04/06/24, and 04/24/24, and 15 individual activities. The log indicated Resident #70 did not attend any the activities that included church services or music. Observation on 04/22/24 at 12:28 P.M. Resident #70 was observed in the common area near the nurses' station of the 100-hall. Attempted interview at this time was unsuccessful. Interview on 04/22/24 at 4:24 P.M. with Resident #70's daughter via phone revealed her concern was the resident was kept medicated at the nurses' station. 365290 Page 16 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0679 Level of Harm - Minimal harm or potential for actual harm Observation on 04/23/24 at 1:29 P.M. of Resident #70 sitting at the 100-hall nurses' station eating lunch with no music or television. Observation on 04/24/24 at 10:57 A.M. of Resident #70 sitting at the nurses' station. A musical activity was occurring in dining/activity area near 300-hall. Residents Affected - Few Interview on 04/24/24 at 11:09 A.M. with State Tested Nurse Aide (STNA) #543 revealed Resident #70 was on his assignment, and the resident liked to attend activities that included music and church services. STNA #543 stated activity staff and the aides would help take residents to activities. STNA #543 stated he was not sure if Resident #70 had gone to the activities today. Observation on 04/24/24 at 11:12 A.M. the live entertainment had ended. Activities Director (AD) #502 turned the tv on, and on Elvis singing. Resident #70 not in attendance. Observations on 04/24/24 at 2:47 P.M. and at 3:35 P.M. of Resident #70 sitting in his wheelchair at the 100-hall nurses' station. Observations 04/29/24 at 9:19 A.M., 9:47 A.M., and at 1:33 P.M. of Resident #70 sitting in his wheelchair at the 100-hall nurses' station. At 1:33 P.M. Resident #70 was eating lunch. Review of the April 2024 activity calendar revealed live entertainment was scheduled on 04/29/24 at 2:30 P.M. Observation on 04/29/24 at 2:41 P.M. of a group of residents outside enjoying the weather. There was no live entertainment observed. Observation on 04/29/24 at 2:44 P.M. of Resident #70 at the 100-hall nurses' station sitting sideways, feet observed out of the leg rest of his wheelchair with no staff observed at this time. Observation at 04/29/24 at 2:47 P.M. of agency STNA #614 came by and adjusted Resident #70 in his wheelchair. Interview at this time with STNA #614 stated there was a live musical entertainment earlier today, and Resident #70 did not attend that activity, but STNA #614 was not sure why. Interview on 04/29/24 at 3:29 P.M. with Activity Director (AD) #502 revealed if Resident #70 was up and out of bed she would take him to activities. Individual activities took place in the residents' rooms or by themselves. The live entertainment for today was pushed up earlier to around 11:15 A.M. due to the entertainer had a death in the family. She thought Resident #70 was in bed at that time. On 04/24/24, entertainment was church service, and she did not recall if Resident #70 attended and had to look at his activity log. Review of the activity log at this time indicated Resident #70 had not attended. AD #502 stated staff often kept Resident #70 at the nurses' station and verified there was no tv or music playing at the nurses' station. She does not always get assistance from staff to take residents to activities. AD #502 stated for four years she was the only person in activities until recently, they hired an activities assistant who covers the memory care unit. Follow-up interview on 04/30/24 at 12:35 P.M., AD #502 verified in the month of April 2024 Resident #70 only attended two group activities, four one on one visits, and the rest were individual activities. Review of the facility policy titled Activity Program, revised June 2018, revealed activity 365290 Page 17 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0679 Level of Harm - Minimal harm or potential for actual harm programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00153001. Residents Affected - Few 365290 Page 18 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104. This affected one resident (#104) of three residents reviewed for activities of daily living. The facility census was 120. Residents Affected - Few Actual Harm occurred on 04/22/24 when Resident #104, who was admitted on [DATE] with severe cognitive impairment and was known to use contact lenses, developed right eye redness and pain and was diagnosed with conjunctivitis (pink eye) which required antibiotic treatment due to a lack of routine eye care for the resident. Findings include: Review of the medical record for Resident #104 revealed an admission date of 11/03/23 with diagnoses including dementia with psychotic disturbance, aphasia (inability to understand and express language), restlessness and agitation, psychotic disorder with delusions, anxiety, and bipolar disorder. Review of Resident #104's plan of care initiated 11/06/23 revealed no focus on eye care or the care of contact lenses. There was a focus on behavior which indicated Resident #104 refused taking her contacts out for regular washing. Interventions included to educate on non-compliance with treatment or care and reapproach with resistance to activities of daily. Review of the nursing progress note dated 11/07/23 revealed Resident #104's family reported Resident #104 wore contacts but had not utilized them since the hospital admission about one month prior and had a history of refusing contacts. Resident #104's family was advised the facility offered house eye exams and eye glass services if needed in the future. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had severe cognitive impairment with no use of corrective lenses. Review of the nurse practitioner progress note dated 11/27/23 indicated Resident #104 was examined with no concerns related to the eyes. The note indicated a contact lens remained within the right eye. Review of Resident #104's physician orders for November 2023 revealed no orders related to eye care or the care of contact lenses. Review of the eye physician's progress note date 12/04/23 revealed Resident #104 was examined and had an air optic color contact lens in the right eye which was removed on this date. Staff were instructed to not let Resident #104 wear contact lenses. Resident #104 was scheduled to return for a follow-up in 12 to 15 months or in six to nine months for a retina evaluation. Review of the nursing progress note dated 01/15/24 indicated Resident #104 placed a contact lens into the right eye. Staff made several attempts to remove the contact lens but Resident #104 continued to refuse. The family was made aware. There was no evidence the resident's physician or nurse practitioner were notified at this time. Review of a social service progress note dated 01/25/24 revealed Resident #104's family decided to 365290 Page 19 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0684 Level of Harm - Actual harm Residents Affected - Few allow Resident #104 to wear contact lenses despite education on the risks of leaving contact lenses in place for lengthy time periods and not removing for routine washing. Nursing staff were made aware. There was no documented evidence that the physician or nurse practitioner were notified. There was no documented evidence nursing staff followed through with the information provided by social services or that the resident's care plan was updated related to the use of contact lenses. Review of Resident #104's physician orders and progress notes from 01/25/24 through 04/21/24 revealed no care or assessments related to Resident #104's use of contact lenses was completed during this time period. In addition, there were no changes to the resident's care plan during this time period or evidence of ongoing resident or family education related to the use of the contact lens. Review of the nursing progress note dated 04/22/24 revealed Resident #104's eye was red, and the resident complained of eye pain. The previous shift reported attempts to remove the right eye contact lens without success. Nursing would request the nurse practitioner to assess Resident #104 on this date. Interview on 04/22/24 at 6:37 P.M. with Resident #104's family revealed a concern Resident #104 had a blue contact lens in the right eye which had been left in place for almost one year. The family member stated it was noticeable because the resident's left eye was green, her natural color, and the right eye was blue, the color of the contact lens. The family indicated staff explained they could not get it out, but stated the eye looked swollen now and it was concerning because the contact lens had been in for too long. Resident #104's family stated the contact lenses were brought in a while back but could not state a time frame. During the interview, the family revealed staff had spoken to the resident's son in January 2024 but not to the resident's first emergency contact. The family member interviewed denied any education or information being provided to him related to the risk of the contact lens use for the resident. Interview on 04/24/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #584 verified Resident #104 had used a contact lens since admission and currently only had one contact lens in the right eye which had been there for a while. LPN #584 confirmed the right eye was now reddened, and the nurse practitioner was supposed to look at the eye, but nothing was provided in report, so LPN #584 was uncertain if anything was done about Resident #104's right eye. LPN #584 further stated staff do try to get the contact lens out of the right eye but Resident #104 would not allow it. LPN #584 indicated personally attempting it over the previous weekend but was unsuccessful. Record review revealed no documentation had been completed to reflect this. Interview on 04/24/24 at 9:02 A.M. with Unit Manager LPN #607 verified Resident #104 had a right eye contact lens in place. LPN #607 revealed Resident #104 was admitted with a contact lens in the right eye. Resident #104 was encouraged to remove the contact lens but refused. The eye doctor had come to the facility and removed it. Social services told the family that due to Resident #104's dementia, it was not best to wear contacts and it was agreed but additional contact lenses were brought in which resulted in Resident #104 placing another contact lens in the right eye. There was never a contact lens in the left eye. Resident #104 would not allow staff to remove it or touch the eye. The family was asked to assist in getting the contact lens out but they had not. The LPN revealed the lens needed to be removed. The LPN also indicated the nurse practitioner was aware of it but not sure what was done about it. Observation on 04/24/24 at 9:15 A.M. with Unit Manager LPN #607 of Resident #104's eyes revealed the left eye was green in color with no abnormal findings. The right eye was blue in color and had 365290 Page 20 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0684 some swelling and redness. There was a red raised area on the mid lower lid, and Resident #104 complained of right eye pain. Level of Harm - Actual harm Residents Affected - Few Interview on 04/24/24 at 9:18 A.M. with Nurse Practitioner (NP) #610 revealed the NP had knowledge of Resident #104 wearing contact lenses and wearing one in the eye at one time but was not aware of Resident #104 wearing the same contact lens for months. NP #610 indicated it was not a good idea for contact lenses to be worn for long periods because it could lead to complications like infection. NP #610 further indicated she had not been previously made aware of Resident #104's right eye being swollen, red, and painful but stated she would look at it on this date. Interview on 04/24/24 at 11:19 A.M. with Unit Manager LPN #607 revealed the eye physician last examined Resident #104 on 12/04/23, and the resident was scheduled to see the eye doctor on each visit thereafter to remove the right contact lens. Review of the nurse practitioner progress note dated 04/24/24 revealed Resident #104 was examined for complaint of right eye pain. Resident #104 was unable to state when it started. The right eye contained a contact lens and now the eye was reddened. The right upper eye lid was swollen and the lower eyelid had a small bump. It was uncertain how long ago the contact lens was placed. Staff reported the family was to come in and assist in removal of the lens and attempts to remove the lens were unsuccessful. Resident #104 previously had a right contact lens removed by the eye doctor but placed a new lens in after removal. The resident had a diagnosis of acute right eye conjunctivitis with a plan to start Besifloxacin antibiotic eye drops (used for the treatment of bacterial conjunctivitis) for seven days and warm compresses to the right eye. Review of the nursing progress note dated 04/24/24 revealed Resident #104's family planned to visit in approximately one week to change the contact lens in the right eye. An additional review of Resident #104's plan of care (initiated 11/06/23), revealed a new focus area was added on 04/25/24 (following surveyor intervention) for the resident's risk of injury related to infection due to use of contact lenses and refusing to allow staff to assist with inserting and removing. Interventions included administer antibiotic as ordered; apply warm compress as ordered; arrange eye care practitioner consult as required; document all refusals to allow staff to assist with contact lens; family would assist with placement and cleaning of contact lenses; keep spouse informed of refusal of assistance with contacts; monitor for, document and report as needed any signs and symptoms of acute eye problems; and per ophthalmology appointment on 12/04/23 Resident #104 not to wear contacts. Review of the eye doctor visits to the facility from 12/04/23 to current revealed the eye doctor was present in the facility on 01/29/24 and 03/25/24. The resident was not seen on either of these dates. Interview on 04/25/24 at 10:15 A.M. with Assistant Social Services Director #605 indicated the eye doctor sets up the visit list and staff add on any resident who needed seen and if residents refused, staff kept re-adding the resident to the next visit list. Resident #104 was known to put contact lenses back into the eyes and staff like it taken out and cleaned, so Resident #104 was on the list routinely for every eye visit. Review of email communication between the facility and eye physician dated 04/25/24 revealed Resident #104's last eye physician examination was on 12/04/23 with a follow-up scheduled for June 2024. 365290 Page 21 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0684 Resident #104 could be seen on the next visit scheduled 05/20/24 if desired and all following visits thereafter. Level of Harm - Actual harm Residents Affected - Few Interview on 04/25/24 at 2:06 P.M. with the Director of Nursing verified the above findings and confirmed the facts were accurate. 365290 Page 22 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview the facility failed to provide adequate assistance, supervision and/or assistive devices to prevent falls and consistently implement fall interventions for Resident #57 and Resident #101. Actual harm occurred on 04/14/24 when Resident #57, who was moderately cognitively impaired and required two staff assist with bed mobility, sustained a fall out of bed when being provided hands on care by only one staff member. The resident sustained a right shoulder fracture as a result of the fall. This affected two residents (#57 and #101) of three residents reviewed for falls. The facility census was 120. Findings Include: 1. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), depression, diabetes, high blood pressure, osteoporosis, and anxiety. A new diagnosis of right shoulder fracture was added on 04/14/24. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was moderately cognitively impaired and was dependent on staff for personal care. Review of Resident #57's falls care plan, initiated on 07/24/19, revealed the resident was at risk for falls due to impaired mobility, impaired decision making, impaired cognition, and impaired safety awareness. The care plan was revised on 01/23/23 to indicate the resident was at increased risk for injury related to osteoporosis. The resident sustained a fall on 01/23/23. An intervention initiated on 01/27/23 was for the resident to have two person assist with care with one on each side of the bed. Review of Resident #57's Kardex (a form which indicates care needs a resident requires) revealed the resident required staff assist of two for bed mobility and hands on care while in bed. Review of Resident #57's progress note revealed on 04/14/24 at 10:15 A.M. Registered Nurse (RN) #602 was called to the resident's room due to the resident rolling out of bed during patient care. The resident rolled over while getting changed and rolled off the bed onto the floor. Resident #57 had an injury to his right elbow and a right knee abrasion. RN #602 notified the physician and an order for an x-ray of the right elbow was given. The x-ray indicated the resident sustained a right shoulder fracture. On 04/18/24 Resident #57 saw the orthopedist who ordered the resident to wear a sling at all times and apply ice to the shoulder for 20 minutes three times a day. A follow-up appointment was scheduled for 05/17/24. Review of the facility's fall investigation for Resident #57's 04/14/24 fall revealed the facility determined the root cause of the fall was he was getting changed. Following the incident the 365290 Page 23 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 Interdisciplinary Team (IDT) implemented a new fall intervention to obtain a wider bed for the resident and add grab bars to the bed. Level of Harm - Actual harm Residents Affected - Few State Tested Nursing Assistant (STNA) #516's written statement regarding the incident dated 04/14/24, revealed she was providing resident care and she rolled Resident #57. STNA #516 said she thought the resident was holding on to the side rail, but he rolled off the bed. STNA #516 stated she first checked the resident and then went and got RN #602. On 04/15/24 STNA #516 was educated on accessing the Kardex and reviewing the resident's mobility status. Interview with Regional Clinical Manager (RCM) #609 on 04/24/24 at 10:15 A.M. regarding Resident # 57's fall on 04/14/24 revealed STNA #516 should have been providing care with another staff member when the resident fell out of bed. The Kardex indicated he was to have an assist of two staff while performing care in bed. Interview with STNA #516 on 04/24/24 at 10:30 A.M. revealed she was the person who was providing care to Resident #57 when he fell out of bed. STNA #516 said the bed was at a normal height. It was not in the high position or the low position. She stated she was changing the resident's fitted sheet when he rolled off the bed. STNA #516 said she had been keeping one hand on him during care except when he rolled over and that was when he fell. She confirmed Resident #57 was supposed to have two staff assist with care while the resident was in bed. STNA #516 confirmed she did not follow the Kardex instructions for care. She said the reason she provided the care alone for the resident was because there was no one available to help her. On 04/24/24 at 10:40 A.M. an observation of Resident #57 revealed he was in bed with a sling to his arm. An interview with the resident at the time of the observation revealed he exhibited confusion and smiled a lot, nodding his head to questions. When asked if he had any pain from the fall he had sustained, the resident stated he was fine. Review of the facility Falls/Accidents/Incidents policy, last revised 07/17/23, revealed the intent of the policy was to ensure the facility provided an environment that was free from accident hazards over which the facility had control and provide supervision and assistive devices to each resident to prevent avoidable accidents. No information was provided on how the facility would accomplish this goal. 2. Review of the medical record for Resident #101 revealed an admission date of 04/18/23. Diagnoses included muscle weakness, abnormalities of gait and mobility, severe protein-calorie malnutrition, and reduced mobility. Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #101 had impaired cognition and had no falls since admission or the prior assessment. Review of the fall risk evaluation dated 03/07/24 revealed a score of nine. Per instructions a total score of 10 or greater, the resident should be considered high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Review of the nurses' note dated 03/31/24 at 8:04 A.M. revealed Resident #101 was observed kneeling on the floor next to the bed holding onto the side rails. Resident #101 stated he was attempting to pick up a pill that he dropped. Resident #101 had no obvious signs of injury. Vital signs were taken and were within normal limits. The resident was assisted back into bed with two staff assist. A 365290 Page 24 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0689 voicemail was left for the resident's niece. The physician and hospice were notified. Level of Harm - Actual harm Review of the interdisciplinary team (IDT) noted dated 04/01/24 at 11:00 A.M. revealed the IDT team met this morning regarding Resident #101's fall that occurred on 03/31/24. The resident was observed kneeling on the floor next to the bed holding onto the side rails. The resident stated he was attempting to pick up a pill that he dropped. The resident had no obvious signs of injury. Vital signs were taken and were within normal limits. The resident was assisted back into bed with two staff assist. A voicemail was left for the resident's niece. The physician and hospice were notified. Risk factors included but were not limited to muscle weakness, communicating hydrocephalus, repeated falls, and reduced mobility. Intervention was to keep bed in lowest position at all times. The care plan and Kardex were updated. Residents Affected - Few Review of the care plan revised on 04/01/24 revealed Resident #101 was at risk for falls related to antidepressant use, history of falls, weakness, episodes of incontinence, balance problem. Interventions included bed in lowest position at all times, and floor mat to left side of the bed while in bed. Observation on 04/22/24 at 3:04 P.M. of Resident #101 in the bed with the bed in the high position with the floor mat folded in corner. Interview at this time with Resident #101 stated he had no concerns with care. Observation on 04/24/24 at 10:55 A.M. of Resident #101 in his room in bed with the bed in high position and no mat to floor. Resident #101 was observed watching tv. Observation on 04/29/24 at 9:42 A.M. of Resident #101 in his room in bed; the bed was not in the lowest position, and there was no mat to the floor next to his bed. Observation on 04/29/24 at 9:58 A.M., with STNA #514 of Resident #101's with the bed not in the lowest position and no floor mat to the floor next to the bed. Interview at this time with STNA #514 verified the observation and pointed to the mat folded in corner near the resident's dresser. Review of the facility policy titled Falls/Accidents/Incidents, revised 07/17/23, revealed the intent of this requirement is to ensure the facility provided an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazards and risks; evaluating and analyzing hazards and risk; implementing interventions to reduce hazards and risk; and monitoring for effectiveness and modifying interventions when necessary. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. 365290 Page 25 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review and facility policy review, the facility failed to complete annual nurse aide performance evaluations as required. This had the potential to affect all 120 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #536 revealed a hire date of 03/07/23. There was no evidence in the personnel file of an annual performance evaluation as required. Review of the personnel file for STNA #537 revealed a hire date of 03/14/23. There was no evidence in the personnel file of an annual performance evaluation as required. Review of the personnel file for STNA #507 revealed a hire date of 04/25/23. There was no evidence in the personnel file of an annual performance evaluation as required. Interview on 05/01/24 at 12:17 P.M. with Human Resource Business Partner #560 verified the above findings were accurate. Review of the facility policy titled Staff Competency, dated 12/31/23, revealed the facility would ensure nurse aides were competent in skills and techniques necessary to care for residents' needs. 365290 Page 26 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review and facility policy review, the facility failed to properly store injectable pharmaceuticals by dating opened containers and failed to maintain clean medication storage refrigerators. This was identified in two of four medication rooms and one of six medication carts which affected one resident (#61) and had the potential to affect all 120 residents residing in the facility. Finding include: During medication storage observation on 04/25/24 at 1:48 P.M. with Director of Nursing (DON) the [NAME] medication cart contained one opened and undated insulin pen (Humalog KwikPen) for Resident #61. Both the [NAME] and Central medication room refrigerators had gross overgrowth of ice from lack of defrosting. The Central medication room refrigerator contained one opened and undated vial of Tuberculin purified protein derivative (Tubersol) solution for intradermal tuberculin testing. Interview at the time of the observation with DON verified the above findings and indicated Tubersol was used for tuberculin testing on residents and employees. Review of the medical record for Resident #61 revealed an admission date of 04/27/23. Diagnoses included diabetes mellitus type II. Resident #61's physician orders effective April 2024 specified Humalog KwikPen subcutaneous (SQ) solution pen-injector 100 Units (U) per milliliter 40 U SQ before meals for hyperglycemia. Review of the facility policy titled Storage of Medications, revised November 2020, revealed nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331. 365290 Page 27 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure meals were served at palatable temperatures. This affected four residents (#37, #59, #63, and #107) and had the potential to affect all residents receiving food from the kitchen. The facility census was 120. Residents Affected - Many Findings include: Interview on 04/22/24 at 12:09 P.M. with Resident #59 revealed the food was terrible, and the hot food was not served hot. Interview on 04/22/24 at 3:14 P.M. with Resident #37 revealed the meals were served cold. Observation on 04/24/24 at 4:17 P.M. revealed Dietary Assistant (DA) #552 obtained food temperatures for dinner from the steam table in the kitchen. The barbeque beef riblet were 188 degrees Fahrenheit, and the baked beans were 160 degrees Fahrenheit. At 5:37 P.M. a test tray was placed on the last meal cart delivered to the 100-hall. The staff immediately began passing the hall trays. At 6:07 P.M. the last meal tray was served, and the test tray was performed with Dietary Manager (DM) #613. DM #613 obtained the temperature of the barbeque beef riblet which was 97 degrees Fahrenheit, and the baked beans were 75 degrees Fahrenheit. DM #613 verified the low temperatures and then tasted the baked beans. DM #613 stated the temperature was not to her liking. Interview on 04/24/24 at 6:10 P.M. with Resident #107 stated she thought the meal tasted good, but it was not hot. Interview on 04/24/24 at 6:11 P.M. with Resident #63 stated dinner was okay, but it was not hot when she received it. Interview on 04/24/24 at 6:13 P.M. with Resident #59 stated she did not like the meal, and it was not hot when she received it. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001. 365290 Page 28 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the menu, the facility failed to ensure Resident #70 was served finger food items per physician's orders. This affected one resident (#70) of three residents reviewed for nutrition. The facility census was 120. Findings include: Review of the medical record for Resident #70 revealed an admission date of 04/28/23. Diagnoses included dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, muscle weakness, alcohol dependence with alcohol induced persisting dementia, and schizophrenia. Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. The assessment indicated the resident required set up or clean up assistance with eating, weighed 140 pounds, had unplanned weight loss, and did not receive a therapeutic or mechanically altered diet. Review of the care plan dated 03/08/24 revealed monitor Resident #70 for potential nutritional problem related to diagnoses of dementia, alcohol dependence with alcohol induced persisting amnestic disorder, and weight loss in one month likely related to improved edema/swelling to both lower legs. Interventions included providing and serving diet as ordered. Review of the physician orders for April 2024 revealed an active order for regular diet, regular texture, thin liquids consistency, finger foods; double eggs with breakfast with a start date of 10/20/23. Observation on 04/23/24 at 1:29 P.M. of Resident #70 eating lunch. Resident #70 was using his hands to pick up and eat strawberries in a bowl that appeared very soft, almost mushy in a liquid. Resident #70 attempted to eat the strawberries with his hands, the liquid spilling down his hand and arm. Observation on 04/23/24 at 1:40 P.M. with State Tested Nurse Aide (STNA) #528 of Resident #70 lunch tray. STNA #528 stated typically Resident #70 was served finger foods. STNA #70 verified the strawberries were in a liquid. Review of the diet spreadsheet indicated frozen strawberries were allowed for the finger food diet. Review of the sliced frozen strawberry recipe revealed to thaw according to package, maybe served chilled or at room temperature. The recipe noted to drain for the easy to chew and finger food diets. Observation on 04/24/24 at 5:42 P.M. Resident #70 was in his room eating his dinner. Resident #70 had barbeque beef riblet, baked beans, roll, sandwich, and cake. Review of the diet spreadsheet indicated that instead of baked beans, frozen green beans were to be served for the finger food diet. Observation on 04/24/24 at 5:46 P.M. with Dietary Manager (DM) #613 of Resident #70's dinner; DM 365290 Page 29 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0805 #613 verified the observation and stated Resident #70 he should have received the green beans. Level of Harm - Minimal harm or potential for actual harm Observation on 04/29/24 at 9:47 A.M. revealed Resident #70 sitting in his wheelchair near the 100-hall nursing station. Sitting in the side of his wheelchair chair was a strip of bacon and white food substance that looked like hot cereal. Residents Affected - Few Observation on 04/29/24 at 10:00 A.M. with STNA #514 of the bacon strip and white food substance in Resident #70's wheelchair seat. STNA #514 verified the observation and stated the resident had eggs, bacon, and oatmeal but used the oatmeal as a painting expedition on the tray table. STNA #514 stated she had to clean the oatmeal off the tray table. Review of diet spreadsheet indicated for cereal of choice, Cereal FF for the finger food diet. Interview on 04/29/24 at 1:30 P.M. with DM #613 stated regarding the frozen strawberry dessert served at lunch on 04/23/24, they added sugar to give it syrup like liquid. DM #613 verified the liquid should have been drained for the finger food diet. DM #613 stated on the diet spreadsheet, the Cereal FF for cereal of choice for the finger food diet indicated finger food cereal. DM #613 stated that included cheerios, flakes, but also hot cereal served in a mug. 365290 Page 30 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect all residents. The facility census was 120. Findings include: Observations on 04/22/24 from 8:54 A.M. to 9:24 A.M. during the initial tour of the kitchen with Dietary Manager (DM) #613 revealed: • An opened, bulk bag of panko sitting on the floor in the dry storage area. • The table where the coffee maker was located revealed the back wall was dirty with various dried food splatter. The three drawers of this table that contained the serving utensils including scoops, spoons, and spatulas, the inside of the drawers was dirty with dark brownish food stains/debris. • The prep sink where the toaster was located revealed the back wall and the silver portion of the table that extended up on the wall had various dried food splatter. The shelf underneath where the cutting boards were located had dried white stains or water spots and various dried food splatter. • The dish room had a slight, malodorous smell, with gnats flying around a bucket with dirty looking rags near dish machine. Underneath the dish machine was various food crumbs, debris, and dried, dirty, darkish substance. The wall near the hand washing sink in the dish machine area had various, dried stains. Interview on 04/22/24 between 8:54 A.M. and 9:24 A.M., DM #613 verified the above findings. Interview on 04/24/24 at 2:45 P.M. with DM #613 stated the odor from the dish room was coming from below related to a plumbing issue. DM #613 stated they had called the plumber. Tour of the nursing unit refrigerators on 04/24/24 from 2:48 P.M. to 2:55 P.M. revealed: • The [NAME] unit freezer had a moderate amount of a frozen substance or spillage. • The East unit refrigerator had various, dried spillage and food debris/crumbs on the shelves, and 365290 Page 31 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0812 the freezer had various, dried spillage and food debris. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Many The memory care unit under the refrigerator, the grill was missing and various trash and debris including an empty juice cup, clear straw wrapper, a cap, etc. were observed. Inside of the refrigerator was dried food spillage, various food crumbs, and two strands of hair on the inside door bottom shelf. The freezer had various, dried spills on the shelves of the inside door. Interview on 04/24/24 between 2:48 P.M. and 2:55 P.M., DM #613 verified the above observations. Observation on 04/24/24 at 3:23 P.M. of Dietary Assistant (DA) #552 pureeing cooked broccoli revealed at 3:31 P.M., the pureed process was completed. DA #552 took the finished pureed broccoli and poured it into the small silver pan with some spilling on the rim of the pan and onto the table. DA #552 grabbed a clean napkin, wiped his hand with the napkin, then used the same napkin to wipe off the spillage on the rim of the silver pan, and then the table. Interview at this time with DA #552 verified the observation. Review of the diet type report revealed all residents in the facility had a diet order to receive meals from the kitchen. Review of the facility policy titled Sanitization, revised November 2022, revealed the food service area is maintained in a clean and sanitary manner. This deficiency represents non-compliance investigated under Complaint Numbers OH00153331. 365290 Page 32 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, Centers for Disease Control and Prevention review and facility policy review, the facility failed to complete admission testing for tuberculosis (TB) for Resident #419. This affected one resident (#419) of seventeen residents reviewed for new admissions. In addition, the facility failed to accurately complete the new hire testing for TB on five new employee (Maintenance Director #594, Licensed Practical Nurse (LPN) #591, LPN #571, Human Resource Business Partner (HRBP) #560, and Assistant Director of Nursing (ADON) #504) of 11 new hire personnel files reviewed. This had the potential to affect all 120 residents residing in the facility. Residents Affected - Many Findings include: 1. Resident #419 was admitted to the facility on [DATE] with diagnoses including stroke, atrial fibrillation, congestive heart failure, chronic kidney disease dependent on dialysis, heart disease, dementia without behavioral disturbance, multiple myeloma, and diabetes. Review of the admission Minimum Data Set (MDS) 3.0 for Resident #419 dated 04/18/24 revealed the resident was moderately cognitively impaired, needed assistance for self-care, received an anticoagulant medication, was on oxygen, attended dialysis, and received speech therapy, occupational therapy, and physical therapy. Review of the progress notes revealed Resident #419 was admitted to the facility on the evening of 04/13/24. There was no documented evidence of TB testing being completed in the medical record. Interview with the Director of Nursing (DON) on 05/01/24 at 11:20 A.M. confirmed she was unable to find documented evidence indicating Resident #419 had been tested for TB upon admission. The DON provided a copy of Computerized Tomography (CT) scan of the lungs performed on 04/05/24 while the resident was in the hospital. The radiologist noted nodules on the lungs but did not indicate what type of nodules they were. Review of the facility's Tuberculosis, Screening Residents for policy, last revised August 2019, revealed the facility will screen all residents for TB infection and disease. The admitting nurse is responsible for screening new admissions for TB. 2. Review of the personnel file for Maintenance Director #594 revealed a hire date of 10/04/23. There was no documented evidence in the personnel file of TB screening or testing upon hire. Review of the personnel file for Unit Manager LPN #591 revealed a hire date of 11/14/23. The first step of the required two-step TB testing was completed on 11/14/23. The second step was administered on 11/24/23 and there was no documented evidence the second step was read within the required 48-to-72-hour timeframe. Review of the personnel file for LPN #571 revealed a hire date of 11/21/23. There was no documented evidence in the personnel file of TB screening or testing upon hire. Review of the personnel file for HRBP#560 revealed a hire date of 03/05/24. The first step of the required two-step TB testing was completed on 03/13/24. The second step was administered on 03/28/24 and there was no documented evidence the second step was read within the required 48-to-72-hour 365290 Page 33 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0880 timeframe. Level of Harm - Minimal harm or potential for actual harm Review of the personnel file for ADON #504 revealed a hire date of 04/03/24. The first step of the required two-step TB testing was completed on 04/03/24. The second step was administered on 04/18/24 and there was no documented evidence the second step was read within the required 48-to-72-hour timeframe. Residents Affected - Many Interview on 05/01/24 at 12:17 P.M. with HRBP #560 verified the above findings were accurate. Review of the facility policy, Tuberculosis, Employee Screening for, revised August 2019, revealed all employees were screened using tuberculin skin test (TST) and symptom screening prior to beginning employment. Review of TB Screening and Testing of Health Care Personnel, updated 08/30/22, from the Centers for Disease Control and Prevention, retrieved from https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm revealed TB screening and testing of health care personnel is recommended as part of a TB Infection Control Plan. TB screening programs should include anyone working or volunteering in a long-term care facility and all health care personnel should be screened for TB upon hire. Review of Testing for TB Infection, updated 07/11/23, from the Centers for Disease Control and Prevention, retrieved from https://www.cdc.gov/tb/topic/testing/tbtesttypes.htm revealed a person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm. This deficiency represents non-compliance investigated under Complaint Number OH00153001. 365290 Page 34 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to assess residents for influenza or pneumonia immunization status upon admission to the facility. This affected two residents (#104 and #105) of 17 residents reviewed for new admission to the facility. The facility census was 120. Residents Affected - Few Findings include: 1. Resident #104 was admitted to the facility on [DATE] with diagnoses including high blood pressure, a stroke, dementia, anxiety, depression, bipolar disease, psychotic disorder, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #104 was severely cognitively impaired and required staff assistance for personal care. Review of the immunization status for Resident #104 revealed the resident had tuberculosis testing upon admission but there was no information on the status of influenza or pneumonia immunization status. On 05/01/24 at 12:14 P.M. the Director of Nursing (DON) confirmed the facility looked for information on influenza and pneumonia immunization but were unable to find any information regarding Resident #104's immunization status. 2. Resident #105 was admitted to the facility on [DATE] with diagnoses including dementia with severe agitation, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, diabetes, traumatic brain injury, and an abdominal aortic aneurysm. Review of the Significant Change MDS 3.0 assessment dated [DATE] revealed Resident #105 was moderately cognitively impaired and needed assistance for all self-care. Review of the immunization status for Resident #105 revealed the resident had tuberculosis testing upon admission, but there was no information on the status of influenza or pneumonia immunizations. On 05/01/24 at 12:14 P.M. the DON confirmed the facility had looked for information on influenza and pneumonia immunization but were unable to find any information regarding Resident #105's immunization status. Review of the facility's Influenza Prevention and Control of Seasonal policy, last revised March 2022, revealed all residents and staff are encouraged to receive the vaccine unless there is a medical contraindication. Review of the facility's Pneumococcal Vaccine policy, last revised March 2022, revealed if the resident is eligible to receive the pneumococcal vaccine series is to be offered within 30 days of admission to the facility unless contraindicated or have previously received it. Education regarding the vaccine is to be provided to the resident/responsible party. Administration of the vaccine are made in accordance with Centers for Disease Control guidelines. 365290 Page 35 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on immunization reviews, staff interview, and education review, the facility failed to offer COVID-19 education and vaccination opportunities for five staff members (State Tested Nursing Assistant [STNA] #509, [NAME] #548, Licensed Practical Nurse [LPN] #588, LPN #590, and Registered Nurse [RN] #599) of five staff members reviewed for COVID-19 immunizations. The facility census was 120. Findings Include: 1. STNA #509's date of hire was 08/25/21. COVID-19 immunization dates were 11/18/21 and 12/22/21. No evidence was provided regarding education being provided or if the vaccine was offered when booster doses became available. The status of the immunization was listed as past due. 2. [NAME] #548's date of hire was 03/21/23. No information was provided regarding if the employee had been educated and offered the COVID-19 vaccination. The status of the immunization was listed as past due. 3. LPN #588's date of hire was 11/01/19. COVID-19 immunization date provided was 03/23/22. No evidence was provided regarding education being provided or if the vaccine was offered when booster doses became available. The status of the immunization was listed as past due. 4. LPN #590's date of hire was 09/21/22. COVID-19 immunization was listed as 01/31/23. No evidence was provided regarding education being provided or if the vaccine was offered when booster doses became available. 5. RN #599's date of hire was 01/31/24. The date of RN #599's last COVID-19 immunization was listed as 12/18/21. No evidence was provided regarding education being provided or if the vaccine was offered upon hire. Interview with the Director of Nursing (DON) on 05/01/24 at 12:14 P.M. confirmed the facility had no information regarding COVID-19 education and offering of the vaccine to their employees. 365290 Page 36 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and review of the contracted quotes, the facility failed to ensure the washers and dryers were in good repair. This had the potential to affect all residents. The facility census was 120. Residents Affected - Many Findings include: Observations on 05/01/24 from 8:48 A.M. to 9:03 A.M. of the laundry area with Housekeeping Manager (HM) #611 revealed in the room with the washing machines revealed a large bin filled to the top with soiled personal clothes and another bin with linens both waiting to be washed. Two of three washing machines were in use, both with linens. The third washing machine was not being used. In the next room over, two of four dryers were being used to dry linens. Interview on 05/01/24 between 8:48 A.M. and 9:03 A.M. with HM #611 verified there was one washing machine and one dryer that did not work. HM #611 stated the washing machine had been down for about seven months, and it was to be fixed but parts could not be found due to the fact that it was an old machine. HM #611 stated he was then told it was to be replaced, but he had not heard anything else about it. HM #611 stated the washing machine was dedicated to residents' clothing, and with it being down, it hindered the turnaround time for clothing to be returned to the residents. The linens were a priority and that bin of residents' clothing filled up fast. Normally turnaround time should take an eight-hour shift to get clothes completed, but it was now taking 24 hours or longer. Three of the four dryers were working. HM #611 stated the one dryer had been down off and on, but he was not sure how long it had been down. Review of work quotes from the contracted company revealed a quote dated 11/07/23 and it noted an estimated repair to repair the washer. In the notes, it stated one of the parts needed from the factory was obsolete. Review of the quote dated 02/29/24 noted to replace the motor on washer was $3,845.55. Review of the quote titled sales and security agreement dated 03/02/24 for a replacement was $14,875.61 and noted a 20% deposit was placed for $2,976.00 leaving balance due of $11,899.61. Attached to this quote was a sticky note with a handwritten note of $9,996.60 to repair. Interview on 05/01/24 at 9:45 A.M. with Maintenance Director #594 stated it had been a while since they called out for the repair for the washing machine. DOM #594 stated corporate wanted the washing machine to be repaired but the quote to repair was about the same as a new one. DOM #594 stated he was not sure what the holdup was. They came out to fix the dryer. DOM #594 stated before the last administrator left, he thought they had decided to replace the washing machine. The last dryer on the end from room with the washing machines went down, and they came to fix that about a month ago. DOM #594 stated the dryer next to that one, third dryer down from the room with the washing machines, hasn't worked in a long while and was not hooked up. DOM #594 stated when he last talked with the contractor, but was not sure when that was, they were waiting for payment. DOM #594 stated he was not sure if it was for the washing machines or the dryer. DOM #594 stated both washing machine and dryer had broken down off and on, and when the contractor last fixed the dryer, he was told continuing to repair them would be difficult due to having to find parts. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001. 365290 Page 37 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy and procedure review, the facility failed to ensure a clean, sanitary, and homelike environment. This had the potential to affect all 120 residents residing in the facility. Findings include: Interview on 04/22/24 at 12:09 P.M. with Resident #59 stated there was a breeze from the window, and maintenance had taped a plastic covering around the window but did not securely tape it in place. Resident #59 stated at night while in bed she feels the breeze and has to bundle up at night. Observation at this time of a clear, plastic covering taped over the window except in the lower left side corner, closer to the resident's bed. Observation on 04/22/24 at 12:29 P.M. of an odor of urine on the 100-hall near the nursing station. Interview at this time with Stated Tested Nurse Aide (STNA) #528 verified the odor of urine and stated it was new as of today. STNA #528 stated housekeeping had been through the rooms and everyone was checked and changed. STNA #528 stated she was not sure where the odor was coming from. Observations on 04/22/24 at 12:35 P.M. revealed the doorway to beauty shop was crumbling at the baseboard. There were water stains on several ceiling tiles by 300-hall dining/activity area. The wall appeared patched or peeled off outside of this dining room. Interview on 04/22/24 at 12:47 P.M. with Resident #43 stated his only concern was there was no closet door to his closet, and he had asked someone about getting a closet door. Resident #43 stated there was no door on the closet when he moved into the room. Observation at this time revealed no closet door to the closet. Observation on 04/23/24 at 1:16 P.M. noted a faint odor of urine on the 100-hall unit near the nursing station. Interview on 04/23/24 at 1:21 P.M. with agency Registered Nurse (RN) #612 stated since she had COVID -19 she had difficulty with her sense of smell but stated she smelled an odor of feces not urine but that was due to one of the residents that was being changed. RN #612 walked from around the nurses' station and stated she now smelled an odor of urine and noted it coming from Resident #6's room. RN #612 stated Resident #6 was non-compliant with care including incontinence care. Follow-up interview on 04/23/24 at 1:42 P.M. with STNA #528 stated they pinpointed the odor of urine was coming from Resident #6's room and she knew the resident may have refused care. STNA #528 stated hospice came in and gave him a bath today, so the resident was clean but verified the odor of urine was still there. STNA #528 stated she believed it was coming from the resident's mattress. STNA #528 stated she had not reported concerns related to the resident's mattress to the management staff. STNA #528 stated she had never heard any complaints regarding the odor from any residents or visitors. Interview on 04/23/24 at approximately 5:30 P.M. Resident #7's family member stated the paper towel dispenser in the resident's room was not working. 365290 Page 38 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0921 Level of Harm - Minimal harm or potential for actual harm Observation on 04/24/24 at 11:01 A.M. of the paper towel dispenser in Resident #7's room revealed the paper towel roll was not inserted in the mechanism to dispense the paper towel. Tour of the facility on 04/25/24 from 9:57 A.M. to 10:25 A.M. with Housekeeping Manager (HM) #611 revealed: Residents Affected - Many • Observation of Resident #66's bathroom revealed the toilet riser over the toilet had dried bowel movement. HM #611 verified the observation and stated nursing was responsible for cleaning it up and housekeeping followed up to disinfect. • Observation in Resident #72's room revealed corrosion around the bottom portion of the wooden drawers connected to the sink and along the wooden strip on the floor of the closet doorway. The molding near the closet was also coming off the wall. Resident #72's bathroom had a quarter sized amount of dried bowel movement behind the toilet and smeared bowel movement near the door of the bathroom. HM #611 verified the observation and stated the corroded wooden areas was the maintenance department responsibility, but housekeeping would get the bathroom floor cleaned up. • Observation of Resident #67's room revealed the floor tiles appeared very worn. Resident #67's bathroom floor and grab bar near the toilet were dusty, and the toilet seat and toilet riser were dirty with hair, dirt, and debris. HM #61 verified the observations and stated the floor tiled needed to be replaced and would require the resident to change rooms. • Observation of Resident #7's paper towel dispenser revealed it was still not functioning. HM #611 stated he just needed to pull the paper towel through the feeder. Observed HM #611, using his key, open the paper towel dispenser and feed the paper towel through so it can be dispensed using the handle. Observed HM #611 lock the paper towel dispenser and pull the handle to dispense the paper towel through and the paper towel did not feed through. HM #611 stated maintenance needed to fix it. • Observation of room [ROOM NUMBER] was noted to be under construction. There was a full rack of clothes, and the room was in disrepair with telephone wall unit hanging off the wall. The wall near the window was in disrepair with the bottom molding piece of windowsill missing with black spots near the left side of window, cobweb in the window, and a portion of the wallpaper was off the wall. There were various items on floor such as a deflated mattress and clear trash bags of various items. HM #611 verified the observations and stated only staff were allowed in the room. HM #611 stated housekeeping was not responsible for cleaning the room. HM #611 stated the rack of clothes was clean, un-named clothing for available for residents who needed clothing. HM #611 stated staff would pull the rack out of the room for residents to look at. Observations on 04/25/24 from 10:49 A.M. to 11:17 A.M. with Maintenance Assistance (MA) #593 365290 Page 39 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0921 revealed: Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Many Observation of Resident #59 window was not completely taped with the clear plastic covering. Interview with MA #593 verified the observation and stated it would get taken care of. MA #593 stated it was normal practice to put plastic over a window and tape it when they received complaints of a breeze. • Observation of Resident #72's room with the corroded wooden drawers connected to the sink, wooden floor strip in the closet doorway, and the molding coming off the wall near the closet. MA #593 verified the observation and stated it corrosion of the wood appeared to be water damage. • Observation of Resident #7's paper towel dispenser. MA #593 stated the paper towel roll was backwards. MA #593 stated he didn't have his keys but would get it fixed. • Observation of Resident #43's room revealed no closet door. Further observation revealed a large, dried brownish stain on the wall under the sink, the bottom part of the wooden drawer connected to the sink was corroded away, and the molding in the front part of the wooden drawers was warped. Interview with MA #593 verified the observations and stated they had been putting up a bar with curtains up in place of the closet doors. MA #593 stated the closet doors they had were too old, but he would get a bar with a curtain to put up. • Observation of the crumbling doorway of the beauty shop with MA #593 verified the observation and stated someone was coming out to give them quotes to repair it. • Observation of water spots on several ceiling tiles near the 300-hall dining/activity area and the peeled paint on the wall outside this area with MA #593 verified the observation and stated he did not know how long it had been this way, but he would get it fixed. Review housekeeping procedures for daily patient room cleaning and bathroom cleaning included: empty trash, horizontal dusting (wipe all flat surfaces), spot clean (all vertical surfaces), dust mop floor, and damp mop floor. Bathroom cleaning included: pulling trash, fill dispensers (soap, paper, etc.), dust mop, sanitize sinks, light, mirror, sink, fixtures, piles, commode, walls, partitions, light switches, and damp mop including behind the commode. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331 and Complaint Numbers OH00153001, and OH00152840. 365290 Page 40 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure handrails were in good repair. This had the potential to affect all residents. The facility census was 120. Residents Affected - Many Findings include: Observation on 04/25/24 at 11:13 A.M. with Maintenance Assistant (MA) #593 of the missing portion of the handrail across from the 300-hall dining/activity area and right next to the area where the puzzles were kept. Interview at this time with MA #593 verified the observation and stated he did not how long it had been that way but would get it fixed. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001. 365290 Page 41 of 42 365290 05/02/2024 Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on record review, interview and facility policy review, the facility failed to complete the required 12 hours of annual training for nurse aides. This had the potential to affect all 120 residents residing in the facility. Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #537 revealed a hire date of 03/14/23. There was no evidence any training was completed toward the required minimum of 12 hours annually. Review of the personnel file for STNA #507 revealed a hire date of 04/25/23. There was no evidence any training was completed toward the required minimum of 12 hours annually. Interview on 05/01/24 at 12:17 P.M. with Human Resource Business Partner #560 verified the above findings were accurate. Review of the facility policy titled Staff Competency, dated 12/31/23, revealed the facility would ensure nurse aides were competent in skills and techniques necessary to care for residents' needs. This deficiency represents non-compliance investigated under Complaint Number OH00153001. 365290 Page 42 of 42