Health inspection·April 14, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to use the correct form to notify Resident #42 and #112 of a change in their skilled nursing benefits. This affected two Residents ( #42 and #112 ) of three Residents reviewed for skilled nursing facility advanced beneficiary notifications (SNFABN). The facility census was 64. Residents Affected - Few Findings included: Record review was conducted of the Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by the facility to the survey team. The form included Resident #42 and Resident #112 as Residents who were identified by the facility to receive a notice called the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form CMS-10055. The facility was asked to provide a completed copy, as provided to Resident #42 and #112, of the SNFABN CMS-10055 forms to the survey team as evidence the Residents were indeed issued the appropriate notifications. Record review was conducted of Advanced Beneficiary Notice (ABN) CMS-R-131 for Resident #42 and #112, as the facility had issued CMS-R-131 to them instead of the SNFABN form CMS-10055. Interview on 04/13/22 at 1:45 P.M. with Social Services (SS) #403 revealed SS #403 was responsible for providing residents with the appropriate notifications of benefits coverage in the facility. She verified she had not issued them the appropriate form CMS-10055 as it was indicated to do so on the SNF Beneficiary Notification Review form. She instead gave Resident #42 and #112 each the ABN CMS-R-131. She said she was not aware she was completing the wrong form. Page 1 of 9 365342 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure resident bathrooms were in good repair. This affected four Residents (#12, #28, #31, and #40) of 19 residents reviewed for physical environment . The facility census was 64. Findings included: Observation on 04/11/22 at 2:43 P.M. of the shared restroom for Residents #12, #28, #31, and #40 revealed bath towels stuffed behind the toilet. A moderate amount of water was observed on the bath towel and the toilet was visibly leaking onto the floor. Observation and interview on 04/13/22 at 7:31 A.M. with the Administrator of the shared restroom for Residents #12, #28, #31, and #40 revealed bath towels stuffed behind the toilet. The Administrator confirmed the toilet was leaking and the bath towels were there to collect the water leaking onto the floor. Interview on 04/13/22 at 8:47 A.M. with Housekeeper #400 confirmed she had been placing a clean bath towel behind the toilet daily after she cleaned the bathroom for Residents #12, #28, #31, and #40. She confirmed a month ago the toilet was leaking, and Maintenance #401 fixed it. She explained it did not leak for at least a month then last week it started leaking again and she had notified Maintenance #401 on 04/07/22. Interview on 04/13/22 at 11:00 A.M. with Maintenance #401 confirmed he did fix the toilet for Residents #12, #28, #31, and #40 a month ago by changing the wax ring and resealing it. He did confirm he was informed the toilet was leaking again on 04/07/22. Maintenance #401 reported he did look at the toilet, but he was unsure how to fix it. Maintenance #401 reported he waited from 04/07/22 to 04/13/22 to call the plumber because he had been busy. 365342 Page 2 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately complete the Preadmission Screening and Resident Review Result notice (PASRR) for a significant change in status. This affected two (Residents #23 and #52) of two residents reviewed for PASRR. The facility census was 64. Findings included: 1. Review of the medical record for Resident #23 revealed an admission date of 08/22/14. Diagnoses included type two diabetes mellitus, chronic kidney disease stage three, and schizophrenia. Review of physician's order dated 05/18/21 revealed Resident #23 was ordered pimavanserin tartrate (antipsychotic medication) for schizophrenia. Review of the significant change of status PASRR dated 01/19/22 for Resident #23 was marked he had no mental illness diagnoses. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 revealed he had a mental illness diagnoses of schizophrenia. Interview on 04/12/22 at 4:00 P.M. with SS #403 confirmed she did answer that question wrong; Resident #23 did have a diagnosis of schizophrenia and she completed the significant change PASSR when Resident #23 was prescribed an antipsychotic medication. Review of the facility policy The Healthcare Electronic Notification System Pre-admission Screening and Resident Review, revised August 2019, revealed a resident review is required for any resident with serious mental illness or intellectual developmental disability who has experienced a significant change in condition. 2. Review of Resident #52's medical record revealed an admission date of 03/15/22 with admission diagnosis that included dementia with behavior disturbance. Further review of the medical record revealed new diagnoses which included psychotic disorder with hallucinations and mood disorder on 03/29/22 after an evaluation from a mental health nurse practitioner. Review of the Pre-admission Screening and Resident Review (PASRR) completed prior to admission to the facility on [DATE] indicated Resident #52 had dementia. No further evidence of mental illness was indicated on this PASRR. No evidence was found of an additional PASRR completed after a new mental illness diagnosis was made of psychotic disorder and mood disorder on 03/29/22. On 04/13/22 at 1:05 P.M. interview with SS #403 verified a new PASRR was required for any new mental illness diagnoses and was not completed. 365342 Page 3 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure a resident, who required an extensive assist of one from staff for personal care, received the assistance needed to keep his fingernails trimmed. This affected one (Resident #57) of four residents reviewed for activities of daily living (ADL's). The facility census was 64. Residents Affected - Few Findings included: A review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included need for assistance with personal care, major depressive disorder, congestive heart failure, Alzheimer's disease, muscle weakness, adult-onset diabetes mellitus, and dementia with behavioral disturbances. A review of Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. His cognition was severely impaired and he was not known to have displayed any behaviors or reject care. He required an extensive assist of one for personal hygiene and was totally dependent with the physical assist of one for bathing. A review of Resident #57's care plans revealed he had a care plan in place for impaired ADL function related to requiring assistance to perform and complete ADL care. The goals included the resident to have his ADL needs met with staff assistance. Interventions included anticipating needs for resident for care, observe for and report to the nurse/ physician a decline or improvement in self-care, and observe resident's ability to perform/ participate in self care activities to determine the need for assistance. A review of Resident #57's shower documentation under the task tab of the electronic health record (EHR) revealed the resident's scheduled shower days were on the day shift on Sundays and Wednesdays. The need to provide nail care with showers was included on the document as well. On 04/12/22 at 11:27 A.M., an observation of Resident #57 noted him to be lying in bed in a supine position with the head of his bed elevated. His fingernails were noted to be long and in need of being trimmed. On 04/13/22 at 8:12 A.M., an observation of Resident #57 noted him to be sitting up in his wheelchair in his room eating breakfast. His fingernails continued to be long and in need of being trimmed. On 04/13/22 at 12:36 P.M., an interview with State Tested Nursing Assistant (STNA) #510 revealed Resident #57 required an extensive assist of one for personal care. She reported she had just given him a shower earlier that day. She was asked what personal hygiene care was provided to the residents as part of their shower and she replied mouth care and hair care. She did not include nail care as one of the activities they would provide as part of his personal care. She denied he was one to be known to refuse any personal care. She was asked who was responsible for providing nail care to the residents. She stated the aides provided nail care unless the resident was a diabetic and then the nurse would trim those residents' fingernails. She was asked if the resident was a diabetic and she was not sure. She stated she would have to check with the nurse. She was then asked how they knew which residents were diabetics when they were giving them a shower to know if their fingernails could be 365342 Page 4 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0677 Level of Harm - Minimal harm or potential for actual harm trimmed or not. She again stated she would have to check with the nurse. She denied that she had checked with the nurse to see if she was able to trim Resident #57's or not. She did not notice that they needed to be trimmed. She was asked to verify the length of his fingernails and confirmed they were long and in need of being trimmed. She checked with the nurse and verified Resident #57 was a diabetic and the nurse would have to trim his fingernails. Residents Affected - Few The facility's Administrator denied having any policies for ADL's or nail care for diabetic residents. 365342 Page 5 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, resident interview, medical record review and staff interview the facility failed to provide joint movement services or splint use for residents identified with limited range of motion. This affected one (Resident #35) of one residents reviewed for range of motion services. The facility census was 64. Findings included: Observation of Resident #35 on 04/11/22 at 12:49 P.M. revealed the right wrist contracted in a flexed position. Additional observation on 04/13/22 at 8:34 A.M. revealed Resident #35 was able to independently complete passive range of motion (manually move an affected joint using something besides the affected extremity ). At no time during the annual survey was any type of splint device or range of motion services observed in place for Resident #35. Review of Resident #35's medical record revealed an admission date of 03/09/18 with admission diagnosis that included cerebrovascular accident with hemiplegia (stroke with weakness to one side of the body). Review of the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 03/04/22 indicated Resident #35 had limitation in functional range of motion (ROM) to one side of his upper extremities. A facility ROM assessment completed on 03/11/22 indicated a severe impairment to the right wrist and right fingers. No evidence of any joint mobility services or splint device use was noted for the right wrist. Review of physician's orders found no evidence of any type of joint mobility services or splint device use in place for the right wrist. Review of Restorative Nursing Services for Resident #35 found no evidence of any type of joint mobility services or splint device use in place for the right wrist. On 04/13/22 at 11:10 A.M. interview with Registered Nurse (RN) #575 verified Resident #35 was at risk for contracture development, had decreased ROM to the right wrist and had no services in place for joint mobility or splint device use. 365342 Page 6 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview and policy review, the facility failed to ensure a resident's fall prevention interventions were implemented as per their plan of care. This affected one (Resident #59) of two residents reviewed for falls. The facility census was 64. Findings included: A review of Resident #59's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, need for assistance with personal care, abnormalities of gait and mobility, dementia with behavioral disturbances and a fall resulting in a displaced fracture of distal phalanx of right lesser toes (3rd and 4th metatarsals). A review of Resident #59's active physician's orders revealed she had an order in place for Dycem to be used in the wheelchair every shift for a fall. The order originated on 03/22/22. A review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. She required an extensive assist of one for transfers and ambulation in her room. She required a limited assist of one for ambulation in the hall. She required supervision with the assist of one for locomotion on and off the unit. A walker and wheelchair were identified as mobility devices being used. The resident was indicated to have had one fall without injury since the prior assessment. A review of Resident #59's care plans revealed she had a care plan in place for having the potential for falls. She was at risk related to incontinence, medication use and impaired vision. The care plan was initiated on 01/26/22. One of the goals developed was for the resident to have her risk of falls minimized. The interventions included the use of Dycem (a tacky material that prevents slipping if placed on a seated surface) to her wheelchair as ordered. The date that intervention was initiated was on 03/22/22. A review of Resident #59's nurses' progress notes revealed a nurse's note dated 03/22/22 at 11:20 A.M. that indicated the aide had notified the nurse of the resident being found on the floor. The resident stated she slipped out of her chair while moving around. A new order was received for the use of Dycem to her wheelchair to prevent slipping. On 04/12/22 at 3:19 P.M., an observation of Resident #59 noted her to be sitting up in a wheelchair in the lounge area. The nursing staff was asked to assist the resident to a standing position to be able to determine if the resident had Dycem in place as per her plan of care. Registered Nurse (RN) #580 and an aide assisted the resident to a standing position and confirmed she did not have Dycem in her wheelchair as part of her fall prevention interventions. They searched her room and could not find any Dycem available for use. On 04/12/22 at 3:22 P.M., an interview with RN #580 revealed Dycem was part of the resident's fall prevention interventions. She was not sure why it was not in place or present in her room for use. A review of the facility policy Managing Falls and Fall Risk, revised 05/06/20, revealed it was the facility's policy to identify interventions related to the resident's specific risks and causes to 365342 Page 7 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0689 Level of Harm - Minimal harm or potential for actual harm try to prevent the resident from falling. The staff would implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If a fall occurred, staff would implement additional or different interventions, or indicate why the current approach remained relevant. Residents Affected - Few 365342 Page 8 of 9 365342 04/14/2022 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #54 received therapeutic dietary interventions to prevent weight loss. This affected one resident (#54) of three residents reviewed for nutrition and weight loss. The facility census was 64. Residents Affected - Few Findings included: Review of Resident #54's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia and chronic pain. Review of Resident #54's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and the resident had a weight loss of 5% (percent) or more in the last month or 10% or more in the last six months. Review of Resident #54's physician orders revealed an order dated 05/13/21 for half a cup (4 ounces) of fortified mashed potatoes at lunch and dinner. Review of Resident #54's care plan revealed an intervention dated 05/22/19 to provide diet and fluids as ordered an an intervention dated 09/22/20 to provide nutritional supplements/snacks/interventions as ordered. Observation on 04/12/22 at 12:30 P.M. of Resident #54's lunch tray revealed a slice of cherry pie, grilled cheese, potato chips, magic cup ice cream, milk, chocolate pudding, peanut butter, and soup. The resident's tray did not include fortified mashed potatoes. Interview on 04/12/22 at 12:30 P.M. with State Tested Nursing Assistant (STNA) # 456 verified the contents of Resident #54's lunch tray did not include fortified mashed potatoes. Interview on 04/12/22 at 2:05 P.M. with Registered Dietitian (RD) #874 indicated Resident #54 had a significant weight loss for the past six months which had stabilized since the addition of fortified mashed potatoes for lunch and dinner, pudding and frozen supplements. Interview on 04/13/22 at 12:47 P.M. with Dietary Manager #686 confirmed Resident #54's fortified mashed potatoes were not included on the meals tickets from 04/04/22 to 04/12/22 due to a new computerized meal ticket tracking system. 365342 Page 9 of 9