Health inspection·January 16, 2025

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 record review, staff interview, and review of the facility policy, the facility failed to ensure care plans were accurate and current. This affected two residents, (#10 and #20) out of five residents reviewed for care plans. The current census was 53. Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of right humerus, unspecified intellectual disabilities, depression, anxiety, insomnia, and pain. Review of Resident #10's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had impaired cognition. Review of the psychiatric diagnostic evaluation dated 02/17/23 revealed the Psychiatric Licensed Social Worker (PLSW) documented Resident #10 had a history of past trauma involving the murder of her brother, abuse by her parent, and abuse by her partner. Per the evaluation ongoing counseling and evaluation from a psychiatrist for medication management was recommended. Review of Resident #10's care plans dated, 01/13/25, revealed a focus added to the care plans for of history of traumatic experiences. No care plan for trauma was added the the resident's care from 11/29/22 to 01/13/25. Interview on 01/15/24 at 3:33 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #10 had reported her past trauma to the social worker sometime during 12/2024. Per the Administrator upon the report the care plan for trauma was not initiated until 01/13/25. Per the DON, Resident #10 did not report the type of trauma and/or any triggers of trauma to anyone prior to 12/2024 per her knowledge. Interview on 01/16/24 at 8:33 A.M. with Social Worker (SW) #380 revealed on 01/03/25 Resident #10 reported to the social worker she had a past trauma of abuse from her family, including her ex-husband. SW #380 stated she reported the trauma to the Administrator but did not document the report. SW #380 denied knowledge of the psychiatric evaluation dated 02/17/23, and stated she was not made aware of the details regarding the resident's trauma until 01/03/25. 2. Review of the medical record for Resident #20 revealed the resident admitted to the facility on [DATE]. Diagnoses included multiple rib fractures post fall, urinary retention, heart disease, and Page 1 of 3 365405 365405 01/16/2025 Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833

F 0656 spinal stenosis. Level of Harm - Minimal harm or potential for actual harm Review of Resident #20's MDS admission assessment dated [DATE] revealed the resident had intact cognition and was admitted to the facility without an indwelling catheter. Residents Affected - Few Review of Resident #20's nursing admission assessment dated [DATE] revealed when the resident re-admitted to the facility on [DATE] he did not have an indwelling urinary catheter. Review of Resident #20's orders revealed the resident was scheduled for an outside appointment with a urologist on 12/23/24. Per the order dated 12/23/24 the resident was ordered to receive indwelling catheter care each shift for the Foley catheter placed. Review of Resident #20's care plans dated from 12/23/24 to 01/13/25 revealed no focus was added to the care plans for the indwelling urinary catheter. On 01/14/25 the staff updated the care plans to add the catheter focus. Interview on 01/16/24 at 10:48 A.M. with Medical Director (MD) 408 revealed when Resident #20 was admitted he was not admitted with an indwelling catheter. Per MD #408, Resident #20 shows signs of urinary retention and was seen by an outside urologist for the issue. MD #408 stated when he returned to the facility from the appointment he had an indwelling catheter placed and the facility staff were caring for the catheter. MD #408 stated the outside urologist is managing the care for the catheter. Interview on 01/16/25 at 11:05 A.M. with Registered Nurse (RN) #350 revealed Resident #20 has had an indwelling catheter for over a month. Interview on 01/16/25 at 11:35 A.M. with the Director of Nursing (DON) verified the care plan was not updated on 12/23/24 when Resident #20 returned to the facility with the indwelling catheter. Per the DON, the care plan was revised after MD #408 had ordered new care orders for the catheter care on 01/14/25. Review of the facility policy titled Comprehensive Care Plans, dated 05/22/18, revealed the facility will ensure all care plans are accurate and current to ensure proper care is provided. 365405 Page 2 of 3 365405 01/16/2025 Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on observation, staff interviews and review of facility policy, the facility failed to ensure proper infection control measures wre followed for nephrostomy collection bag. This affected one Resident #144 of two reviewed for urinary catheter care. The facility census was 53. Findings included: Review of medical record for Resident #144 revealed an admission date of 01/10/25. Diagnoses included hydronephrosis with renal and ureteral calculous obstruction with a nephrostomy. Observation on 01/16/25 at 6:57 A.M revealed the resident was lying on his left side with the nephrostomy drainage bags hanging off the left side of the bed touching the ground. Interview with Certified Registered Care Associate (CRCA) # 329 on 01/16/25 at 7:15 A.M. verified the drainage bags were over the left side of the bed and touching the floor. Review of the policy titled Urinary Catheter Care, dated 12/16/24, revealed the urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor. 365405 Page 3 of 3