Health inspection·November 20, 2023

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. 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, and review of the facility policy, the facility failed to provide adequate preparation for resident transfer/discharge from the facility. This affected one resident (Resident #70) out of three residents reviewed for transfers and discharges. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record for Resident #70 revealed the resident was admitted on [DATE] with diagnoses including cerebral palsy, diabetes mellitus, bipolar disorder, schizophrenia, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/29/23 revealed the resident was cognitively intact and able to make her needs known. Review of nursing and social services notes for Resident #79 revealed they did not include documentation of the resident's request to transfer to another facility. Interview on 11/19/23 at 1:00 P.M. with the Director of Nursing (DON) confirmed Resident #70 had requested a transfer to a specific facility in the last two weeks. Interview with the DON confirmed the facility staff had made a referral to the requested facility, but the request was denied due to the resident had previously left the facility against medical advice twice. Interview with the DON confirmed social services should be able to provide a record of the transfer requested and the result. Interview on 11/19/23 at 3:00 P.M. with Social Services Director (SSD) #400 confirmed she had placed a call to the requested facility of Resident #70 on or around 11/12/23 or 11/13/23. SSD #400 further confirmed the requested facility declined to accept Resident #70 for admission as they had turned the facility into a drug rehabilitation facility. Further interview with SSD #400 confirmed she was unable to provide documentation of transfer and discharge planning for Resident #70. Review of the facility policy titled Documentation of Transfers/Discharges dated December 2008 revealed all documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00147963. Page 1 of 4 365293 365293 11/20/2023 MT Airy Gardens Rehabilitation and Nursing Center 2250 Banning Road Cincinnati, OH 45239

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and staff interview the facility failed to ensure the resident care environment was free of accident hazards. This had the potential to affect the 21 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who resided on the secured dementia unit and were identified by the facility as being confused and able to ambulate or propel themselves independently. The facility census was 74. Findings include: Observation on 11/19/23 at 11:00 A.M. on the secured dementia unit of the facility revealed there was a portable space heater approximately three feet long and six inches tall on the floor with the cord taped to the floor and wall of Resident #1's room. The portable spaced heater was plugged into the outlet in the wall and was turned on with heat being put out into the room. There was a warning printed on the top of the portable space heater which read Caution - high temperatures, keep electrical cords, drapes and other furnishings away from the heater. Fire hazard, do not operate without feet attached. Observation on 11/19/23 at 11:15 A.M. on the secured dementia unit of the facility revealed there was a portable space heater approximately three foot long and six inches tall sitting on the floor in between the door to the room and resident's bed in Resident #2's room. The portable space heater was plugged into the outlet in the wall and was turned on with heat being put out into the room. There was a warning printed on the top of the portable space heater which read Caution - high temperatures, keep electrical cords, drapes and other furnishings away from the heater. Fire hazard, do not operate without feet attached. Interview on 11/19/23 at 11:25 A.M. with Licensed Practical Nurse (LPN) #200 confirmed portable space heaters had been in use Resident #1 and #2's rooms for approximately two weeks due to the heaters in the rooms being broken. Observation on 11/19/23 at 11:27 A.M. revealed a plastic spray bottle which was over half full of liquid was located in the top right cabinet in the dining room of the secured dementia unit and the cabinet was not locked. The word bleach was written on the bottle in black marker. There were eight residents present in the dining room at the time of the observation with no staff members present in the room. Interview on 11/19/23 at 12:05 P.M. with the Director of Nursing (DON), Maintenance Director #500, and Housekeeping Director #600 confirmed there was a plastic spray bottle containing a clear liquid labeled with the word bleach in the unlocked kitchenette cabinet in the dining room of the secured dementia unit. Interview confirmed the substance in bottle was presumed to be bleach and should be secured in a locked cabinet. Further interview confirmed there were portable space heaters in use for Residents #1 and #2 due to the heaters in the rooms not working. Interview on 11/19/23 at 2:15 P.M. with the DON confirmed all 21 residents residing on the secured dementia unit were able to ambulate or propel themselves independently in their wheelchairs and were at risk for potential burns related to the use of portable space heaters in resident rooms. This deficiency represents non-compliance investigated under Complaint Numbers OH00148343, 365293 Page 2 of 4 365293 11/20/2023 MT Airy Gardens Rehabilitation and Nursing Center 2250 Banning Road Cincinnati, OH 45239

F 0689 OH00148048, and OH00147693. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365293 Page 3 of 4 365293 11/20/2023 MT Airy Gardens Rehabilitation and Nursing Center 2250 Banning Road Cincinnati, OH 45239

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff interviews, and review of facility policies, the facility failed to ensure resident rooms and common areas were clean and well-maintained. This had the potential to affect the 21 residents (#1, #2, #3, #4, #5, #6. #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who resided on the secured dementia unit. The facility census was 74. Findings include: Observation on 11/19/23 at 11:00 A.M. revealed there was dried, red juice on the floor in Resident #1's room. The closet doors were broken and hanging off the tracks. The toilet handle was broken and hanging down. The toilet seat was broken off and lying on the floor beside the toilet. The bathroom light switch cover was missing. Interview on 11/19/23 at 11:25 A.M. with Licensed Practical Nurse (LPN) #200 confirmed the maintenance and cleanliness concerns observed in Resident #1's room. Observation on 11/19/23 at 11:27 A.M. revealed the dining room floor in the secured dementia unit had black stains across the majority of the floor. The kitchenette located in the dining room had several cabinet doors which were broken and hanging loose and several of the drawers were broken. Interview on 11/19/23 at 12:05 P.M. with the Director of Nursing (DON), Maintenance Director (MD) #500, and Housekeeping Director (HD) #600 confirmed the dining room floor of the secured dementia unit were covered in a black substance and needed to be stripped. Further interview confirmed the cabinet doors and drawers on the kitchenette were broken and were in need of repair. Observation on 11/19/23 at 1:55 P.M. revealed the wallpaper in the two hallways of the secured dementia unit was missing, torn, or peeling off in places. There were also areas in which the walls had been patched but were still in need of being painted. There were also tiles in the right rear corner of the shower stall in the shower room on the secured dementia unit which were loose and sticking out from the wall. Interview on 11/19/23 at 1:55 P.M. with the DON and MD #500 confirmed the concerns regarding the torn and missing wallpaper in the hallways, the patched areas on the wall in need of paint, and the loose tiles in the shower room. Review of the facility policy titled Maintenance Service revised 12/2009 revealed the maintenance department was responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. Review of the facility policy titled Cleaning and Disinfecting Resident's Rooms undated, revealed housekeeping surfaces (example floors, tabletops) would be cleaned on a regular basis, when spills occurred, and when these surfaces were visibly soiled. This deficiency represents non-compliance investigated under Complaint Numbers OH00148343, OH00148048, and OH00147693. 365293 Page 4 of 4