Health inspection·February 8, 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 interview and record review the facility failed to ensure that witness authorizations were obtained to manage resident funds. This affected five residents (#1, #6, #24, #26, and #56) of five reviewed for personal funds. This had the potential to affect 33 residents whose funds were managed by the facility. The census was 58. Residents Affected - Some Findings include: Review of financial records for Residents #1, #6, #24, #26, and #56 revealed no witness signatures on the Authorization and Agreement to Handle Resident Funds Forms. On 02/06/24 at 2:55 P.M., an interview with the Administrator verified there were no witness signatures on the Resident Fund Management Agreement Forms. On 02/06/24 at 9:40 A.M. an interview with Business Office Manager # 511 verified there were no witness signatures on the Resident Fund Management Agreement Form. Page 1 of 9 365342 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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, policy review, and interview, the facility failed to complete a comprehensive assessment to determine if side rails were used as a restraint or an enabler. This affected one (Resident #56) of 24 residents observed for possible restraints. Te census was 58. Residents Affected - Few Findings include: Review of Resident #56's medical record revealed diagnoses including severe dementia with agitation, abnormal posture, mood disorder, generalized muscle weakness and Parkinson's disease. An admission assessment dated [DATE] indicated Resident #56 had a siderail screening tool which indicated Resident #56 was non-ambulatory, had alterations in safety awareness due to cognitive decline, had a history of falls, demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was currently using side rails raised while in bed, and had not expressed a desire to have rails raised while in bed. The assessment indicated siderails were indicated and served as an enabler to promote independence. The functional status of the admission assessment indicated Resident #56 was totally dependent for bed mobility. Review of a baseline care plan dated 04/10/23 indicated Resident #56 had the potential for falls with interventions for 1/2 or 1/4 side rails up when in bed. Review of a care plan initiated 04/18/23 indicated Resident #56 was at risk for falls and fall related injury related to a history of falls with fracture prior to admission, muscle weakness, unsteadiness on her feet, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, disorientation, depression, age-related physical disability, atrial flutter, Alzheimer's disease, dementia, Parkinson's disease, and poor safety awareness. On 05/19/23 an order was written for bilateral enabler bars to assist with bed mobility, turning and repositioning, transfers and to promote independence. The care plan related to fall risk was updated to include an intervention dated 06/19/23 for the use of bilateral enabler bars to assist with bed mobility, positioning, and transfers. There was no evidence of assessments for side rail/enabler bar use after the admission assessment. On 02/05/24 at 10:18 A.M., Resident #56 was observed lying in bed with bilateral quarter side rails which were raised and located on the lower top half of the bed. On 02/05/24 at 11:26 A.M., Resident #56 remained in the bed with the side rails raised. A family member who was present stated the side rails were raised to prevent falls. Subsequent observations on 02/05/24 at 2:59 P.M., on 02/06/24 at 10:26 A.M., 11:15 A.M. and 4:32 P.M., and on 02/07/24 at 5:37 A.M. revealed Resident #56 was in bed with the side rails raised. Resident #56 was not observed using the rails for mobility or repositioning herself. On 02/06/24 at 4:44 P.M., Licensed Practical Nurse (LPN) #520 stated she was unaware of any side rails assessments being completed to determine if the side rail/mobility bars restrained movement. At 5:08 P.M., LPN #520 added Resident #56 would sometimes grab hold of the bar when being transferred with a gait belt and two assists. However, Resident #56 did not have enough strength to hold herself 365342 Page 2 of 9 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0604 Level of Harm - Minimal harm or potential for actual harm up. LPN #520 also stated Resident #56 would squirm in bed but did not make an effort to reposition herself or turn in bed with use of the rail/enabler bars. On 02/07/24 at 9:30 A.M., LPN #520 verified she could find no siderail assessment since Resident #56's admission. LPN #520 stated the use of siderails should be assessed quarterly. Residents Affected - Few During an interview on 02/07/24 at 4:07 P.M., State Tested Nursing Assistant (STNA) #543 stated Resident #56 squirmed in bed and sometimes got her legs over the bed but believed the rail might prevent her upper body from leaving the bed. Resident #56 did not use the rail for bed mobility or transfers. The rail was lowered before transferring Resident #56 to prevent skin tears/injury. During an interview on 02/07/24 at 4:40 P.M., Registered Nurse (RN) #581 stated she had Resident #56's siderails/enabler bars reassessed. The assessment indicated Resident #56 no longer used the side rails/enablers for bed mobility but that she sometimes got her legs out of the bed and it aided in her not falling from the bed. RN #580, who was also present, stated Resident #56 used to use the siderails for mobility but it was unclear when she was no longer able to. Review of the facility's Mobility Bars policy, dated November 2016 and reviewed/revised 02/06/24 indicated the facility would only use mobility bars to assist in bed mobility and transfer when it was appropriate. The therapy department or designee should work with nursing to assess the suitability of mobility bars for residents. The assessment should be done on admission, quarterly and with any major changes in residents' function. 365342 Page 3 of 9 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

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** 2. Review of Resident #35's medical record revealed diagnoses including depression, anxiety disorder and Alzheimer's disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated contradictory information regarding medication use. One section of the MDS indicated Resident #35 did not receive antipsychotic medication while another section indicated Resident #35 received antipsychotic medication on a routine basis only with a gradual dose reduction attempted 10/06/23. Review of the November 2023 Medication Administration Record (MAR) revealed no antipsychotic medications were administered. Residents Affected - Few On 02/07/24 at 9:53 A.M., Registered Nurse (RN) #581 verified the coding on the quarterly MDS dated [DATE] was inaccurate as Resident #35 was not receiving antipsychotics on a routine basis. Based on medical record review and staff interview the facility failed to ensure comprehensive assessments were completed accurately related to hospice services and medication use. This affected two (Resident #18 and #35) of 19 residents reviewed for comprehensive assessments. The facility census was 58. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 03/18/17 with diagnoses that included congestive heart failure, dementia and chronic kidney disease. Further review of the medical record including physician's orders revealed on 02/26/23 Resident #18 was admitted to hospice services. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 11/03/23 indicated Resident #18 was not currently receiving hospice services. A previous quarterly MDS 3.0 assessment with a reference date of 08/03/23 indicated the resident was receiving hospice services. On 02/07/23 at 9:53 A.M. interview with [NAME] President of Clinical Services #581 verified the MDS with a reference date of 11/03/23 did not indicate Resident #18 was currently receiving hospice services. 365342 Page 4 of 9 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, policy review and staff interview the facility failed to ensure Resident #21 was turned and repositioned as per the care plan and ordered by the physician. The facility also failed to accurately stage pressure ulcer wounds for Resident #44. This affected two (Residents #21 and #44) of two resident reviewed for pressure ulcer wounds. The facility census was 58. Residents Affected - Few Findings include: 1. Review of Resident #21's medical record revealed an admission date of 07/05/22 with admission diagnoses that include a stage four pressure ulcer (full thickness skin loss with exposed bone, tendon or muscle) to the sacral region, Parkinson's disease with dementia and chronic kidney disease. Review of wound assessments revealed a chronic unhealed stage four pressure ulcer wound to the sacrum/coccyx area which was present upon admission. Review of Resident #21's Minimum Data Set (MDS) quarterly assessment with a reference date of 11/08/23 indicated the resident had a severely impaired cognition level and was dependent upon staff assistance for bed mobility. Further review of the medical record including physician's orders dated 07/05/22 staff were to encourage the resident to turn and reposition every two hours. Review of Resident #21's plan of care related to impaired skin integrity revealed an intervention to turn and reposition the resident every two hours. Observation of Resident #21 on 02/06/24 from 9:37 A.M. to 3:17 P.M. revealed the resident lying in bed on her back with no evidence of turning and repositioning. Interview with State Tested Nurse Aide (STNA) #524 on 02/06/24 at 3:20 P.M. verified Resident #21 had not been turned and repositioned since early that morning. STNA #524 indicated the resident prefers to stay on her back and previous use of foam wedges for positioning failed due to comfort of the resident. Interview with the Director of Nursing on 02/06/24 at 3:40 P.M. verified Resident #21's care plan did not indicate a preference to remain on her back and non-compliance with turning and repositioning. Review of the facility policy titled Turning and Repositioning with an implemented date of 10/25/23 and reviewed/revised on 02/08/24 indicated; All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. The frequency of turning and repositioning will be documented in the resident's plan of care. 2. Review of Resident #44's medical record revealed an admission date of 04/16/22 with diagnoses that included dementia, diabetes mellitus and congestive heart failure. Review of Resident #44's weekly skin assessments revealed on 12/27/23 a suspected deep tissue injury (SDTI (purple or maroon localized area of discolored skin, may include a thin blister over a dark wound bed)) to the right heel was found. Further review of the weekly wound assessments revealed the 365342 Page 5 of 9 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0686 Level of Harm - Minimal harm or potential for actual harm wound was described as dry with 100% eschar (leathery, scab like tissue) to the wound from onset to the last assessment completed on 02/05/24. Review of the weekly wound nurse practitioner consultant assessments revealed the wound was initially staged as a SDTI on 01/08/24 and then changed to an unstageable pressure ulcer wound on 01/15/24. Residents Affected - Few Observation of wound care for Resident #44 on 02/07/24 at 8:45 A.M. with Licensed Practical Nurse (LPN) #582 revealed a wound to the right heel. The wound bed was covered with 100% black and dry eschar tissue. On 02/07/24 at 8:55 A.M. interview with LPN #582 revealed she described the wound as an unstageable pressure ulcer wound. Additional interview on 02/08/24 at 8:12 A.M. with LPN #582 verified inaccurate wound assessment which indicates wound is a suspected deep tissue injury and is currently an unstageable wound as indicated by wound nurse consultant. Review of the facility policy titled Documentation of Wound Treatments with a date implemented of 2016 and Review/Revised date of 02/08/24 indicated; the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment. The following elements are documented as part of a complete wound assessment: stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury). 365342 Page 6 of 9 365342 02/08/2024 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and interview, the facility failed to ensure residents disposed of cigarettes in the designated containers and that facility staff supervising residents smoking knew where the fire safety devices were located. This affected four residents (#3, #14, #19, and #20) of four identified by the facility as smokers. The facility census was 58. Findings include: On 02/05/24 at 9:12 A.M., observation of the courtyard, which was the designated resident smoking area, revealed there were 23 cigarette butts scattered throughout the grass, 21 cigarette butts scattered throughout the mulch, and six cigarette butts on the sidewalk. There was no fire extinguisher or fire blanket in the designated smoking area. On 02/05/24 at 9:26 A.M., interview with Licensed Practical Nurse (LPN) #582 verified cigarette butts were in the grass, mulch, and on the sidewalk. LPN #582 confirmed there was no fire extinguisher or fire blanket in the exterior courtyard which was the designated smoking area for residents. On 02/05/24 at 9:37 A.M., interview with Housekeeper #568, who was supervising residents smoking, stated she did not know where the fire blanket was and she confirmed the nearest fire extinguisher was inside the building on the other side of the resident common area. 365342 Page 7 of 9 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation and interview, the facility failed to ensure there was sufficient staff to monitor dining activities on the secure unit. This had the potential to affect all 19 residents who resided on the secure unit. The facility census was 58. Findings include: During observations of the lunch meal delivery and service on 02/05/24 of the secure unit the following was observed: The first meal cart arrived at 12:25 P.M. and staff immediately began serving residents. At 12:43 P.M. all other residents at the main/long table in the dining room were eating or had received their trays with the exception of Resident #12. No staff were present at the table or directly monitoring the residents when Resident #12 reached over and took a bowl of applesauce from Resident #53's tray and started drinking the applesauce from the bowl. When staff did observed Resident #53 with the applesauce they stated they did not know where Resident #53 got it from. At 12:45 P.M., State Tested Nursing Assistant (STNA) #521 sat beside Resident #12 to assist with her meal. One bowl of food was provided with staff providing cues and physical assistance. The last two bowls were provided at the same time. At 1:02 P.M., Resident #53, who had orders for a pureed diet, was observed with two bowls of regular carrots, one of which he had taken from Resident #12. Staff intervened after Resident #53 already had a regular carrot in his mouth telling him he was on a pureed diet and could not eat regular carrots. At 1:05 P.M., staff noted Resident #32 had left the table without eating much and asked staff on the floor to redirect him back to the dining room. Resident #32 was overheard indicating he did not want to eat any more. Resident #303 was observed pushing a piece of pie across the table to Resident #28 who was also eating a pureed diet. STNA #546 was informed of this by the surveyor prior to intervening and verified Resident #28 was on a pureed diet and should not have regular pie. At 1:39 P.M., Resident #32 was observed sitting at a table at the end of the hall near the nursing station eating food from Resident #54's tray. After about 20 second staff walking down the hall observed this and intervened. On 02/05/24 at 1:30 P.M., STNA #521 stated there was not enough staff to monitor resident behaviors and feed residents at meal time on the secure unit. STNA #543 agreed. Both STNA #521 and #542 acknowledged residents were taking food from one another and the food was not always appropriate for residents' diets. On 02/06/24 at 4:22 P.M., STNA #508 stated there was not sufficient staff on the secure unit because residents liked to wander and behaviors could be better monitored with a third aide. STNA #508 stated staffing was not sufficient enough during meals to prevent residents from taking one another's food or sharing food which was inappropriate for diets. 365342 Page 8 of 9 365342 02/08/2024 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/06/24 at 4:55 P.M., Registered Nurse (RN) #571 stated there were some residents on the secured unit who fixated on food and who were sometimes able to get food which was inconsistent with their diets. It would be beneficial to have more staff to monitor behaviors. On 02/07/24 at 4:07 P.M., STNA #543 stated the secured unit had multiple residents with behaviors. Some of the residents required two assists to provide personal care which tied up both aides on the unit. The STNAs tried to reserve those residents' care to be provided when the nurse was available to monitor behavior of other residents. However, it was difficult to monitor residents with behaviors at times as they were mobile and behaviors could escalate quickly. On 02/08/24 at 1:55 P.M., STNA #546 verified after Resident #STNA #521 left the dining room on 02/05/24 during lunch and she was the only staff member monitoring the other residents she was unable to monitor the residents closely enough to prevent them from sharing and taking food. STNA #546 indicated she was asked to assist in the secure dining room on 02/05/24 but she did not normally do so. The facility identified Residents #7, #9, #12, #16, #24, #28, #30, #32, #35, #36, #39, #40, #43, #53, #54, #55, #56, #57, and #113 as residing on the secure unit. Review of the facility's policy, Nursing Services and Sufficient Staff, implemented October 2022 and reviewed/revised 02/06/24, indicated the facility's census, acuity and diagnoses of the resident population would be considered based on the facility assessment. The facility was to supply sufficient direct care services on a 24-hour basis to meet the needs of residents in an appropriate and timely manner. The facility would determine the number and type of additional staff required based on the services needing to be performed as identified in the care plan. 365342 Page 9 of 9