Health inspection·February 4, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on medical record review, staff interview and resident interview, observation and policy review, the facility failed to ensure residents had appropriate clothing to wear. This affected one resident (#434) of three residents (#09, #78, and #434) reviewed for dignity. The facility census was 84. Findings include: Review of the medical record for Resident #434 revealed an admission date of 01/14/22. Diagnoses included displaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of right lower leg, subsequent encounter for closed fracture with routine healing, benign prostatic hyperplasia with lower urinary tract symptoms, morbid obesity due to excess calories, obstructive sleep apnea and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 01/21/22 revealed Resident #434 had intact cognition. The resident required limited assistance for bed mobility, total dependence for transfer, extensive assistance for dressing, personal hygiene, and toilet use and supervision for eating. Observation on 01/27/22 at 12:06 P.M. revealed Resident #434 was wearing a hospital gown. Interview on 01/27/22 at 12:07 P.M., with Resident #434 revealed staff gave him the hospital gown to wear. He reported he had limited clothing at the facility. Interview on 01/27/22 at 12:11 P.M., with Licensed Practical Nurse (LPN) #123 verified Resident #434 had on a hospital gown. Review of the facility policy titled Dignity Policy, revised 02/2021, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Page 1 of 27 365423 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to ensure resident advance directives were accurate. This affected one resident (#02) of three residents (#02, #09 and #49) reviewed for advance directives. The facility census was 84. Findings include: Review of the medical record for Resident #02 revealed an admission date of 02/19/21. Diagnoses included pulmonary embolism, cognitive communication deficit, other cerebral infarction due to occlusion or stenosis of small artery, chronic obstructive pulmonary disease, hypertensive encephalopathy, atrial fibrillation, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had moderate impaired cognition. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene and supervision for eating. Review of the electronic health record revealed the resident had an order for a Full Code status dated 02/19/21. Review of the paper chart revealed the resident had a Do Not Resuscitate Comfort Care-Arrest order dated 03/31/21. Interview on 01/26/22 at 5:23 P.M., with Licensed Practical Nurse (LPN) #118 confirmed the discrepancy regarding Resident #02's code status. Review of the facility policy titled Mt. [NAME] Care Center Advance Directives, revised 12/2016, revealed the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 365423 Page 2 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, staff and family interview, and policy review the facility failed to maintain resident room environment in a clean, sanitary and comfortable manner. This affected three residents (#07, #25 and #48) of eight residents who resided in the seven rooms observed. The facility census was 84. Findings include: Observation on 01/24/22 at 11:36 A.M., revealed Resident #25's floors was covered with debris, loose straw wrappings, dead flower leaves and wipes. Interview on 01/24/22 at 11:45 A.M., revealed Resident #25 reported she has not had her room cleaned in a few days. Observation on 01/24/22 at 11:56 A.M., revealed Resident #07's floors were stained, and paper was on the floor. Resident #07 was unable to answer interview questions. Observation on 01/24/22 at 12:00 P.M., revealed Resident #48's floors were dirty with debris and the bedside table was stained. Interview on 01/24/22 at 12:02 P.M., revealed Resident #48's family member reported staff mopped over the dirty floors and they do not clean the bed side tables. Interview on 01/24/22 at 12:28 P.M., revealed Housekeeper (HK) #26 stated the facility was short staff for housekeepers. HK #26 verified findings of Resident (#07, #25 and #48's) rooms were not clean. HK #26 reported a new housekeeper was scheduled for Resident (#07, #25 and 48) rooms. Interview on 01/24/22 at 12:36 P.M., revealed HK #21 was the new housekeeper and reported the facility was short staffed, and she had over 20 rooms to complete. HK #21 reported she was assigned to Resident (#07, #25 and #48's) rooms and but had not started on those rooms yet. HK #21 reported she was new and it was her first time doing housekeeping. Observation on 01/25/22 at 10:48 A.M., revealed Resident #25's room had similar debris on floor and dead poinsettia leaves on the floor. Interview on 01/25/22 at 11:36 A.M., revealed Housekeeping and Laundry Supervisor (HKS) #07 revealed, housekeepers clean about 18 to 20 rooms a day. She was trying to hire more staff. HKS #07 verified Residents (#25 and #48's) room being dirty. Review of the Environmental Service Check List undated revealed floors should be mopped and checked daily. The housekeeper should dust, clean chairs, furniture, night stands and dressers. This deficiency substantiates Complaint Number OH00129093, Complaint Number OH00129099 and Complaint Number OH00110816. 365423 Page 3 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place. This affected one resident (#382) out of three residents (#68, #70, and #382 residents reviewed for PASRR status. The facility census was 84. Residents Affected - Few Findings include: Record review revealed Resident #382 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction, anemia, pulmonary edema, acute embolism, chronic obstructive pulmonary disease, major depressive disorder, COVID-19, essential primary hypertension, and cognitive communication deficit. Review of the Minimum Data Sheet (MDS) 5-day assessment, dated 12/20/21, revealed Resident #382 required limited assistance from staff with bed mobility, transfers, dressing and extensive assistance from staff with e. Resident #382 was independent with eating. Review of the medical record revealed no evidence a new PASRR was submitted for approval to the State agency following the expiration of the hospital exemption form for Resident #382, dated 12/15/21. Interview on 01/24/22 at 3:00 P.M. with Social Services Director (SSD) #04 confirmed a PASRR was not requested for Resident #382 following the expiration of her hospital exemption dated 12/15/21. SW #04 revealed the facility failed to complete a PASRR review for Resident #382. Review of the facility policy for PASRR titled, admission Policy, dated 03/19, revealed the facility failed to implement their policy. The Policy stated under #9 section a., The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. 365423 Page 4 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review, interview, and policy review the facility failed to develop a baseline care plan for residents. This affected two residents (#68 and #382) of three residents reviewed for baseline care plans. The facility census was 84. Findings include: 1. Review of the medical record for resident #68 admitted to the facility on [DATE]. Diagnoses included, non-displaced fracture of medial malleolus of right tibia, Covid 2019 (Covid 19), gastro-esophageal reflux disease, major depressive disorder, essential primary hypertension, hypothyroidism, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) admission assessment for Resident #68 dated 12/28/21 revealed the resident had moderately impaired cognition. Resident #68 required limited assistance from staff for bed mobility, however, he required extensive assistance from staff with toilet use, personal hygiene. Resident #68 required supervision from staff with eating and he was totally dependent on staff with bathing. Further review of the medical record for Resident #68 revealed the facility failed to implement a baseline plan of care. 2. Record review revealed Resident #382 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, anemia, anemia, acute pulmonary edema, essential primary hypertension, acute embolism, chronic obstructive pulmonary disease, major depressive disorder, Covid-19, and cognitive communication deficit. Review of the Minimum Data Sheet (MDS) five day assessment dated [DATE] revealed Resident #382 required limited assistance from staff with bed mobility, transfers, dressing and extensive assistance from staff with. Resident #382 was independent with eating and required no assistance from staff. Review of the baseline care plan for Resident #382 revealed the facility failed to implement a baseline care plan for her. Interview on 01/26/22 at 10:52 A.M., with the Minimum Data Set (MDS) Nurse #11 confirmed the facility failed to implement a baseline care plan for Resident #68 and Resident #382. Review of the facility policy title, Care Center Care Plans - Baseline, dated 12/16 revealed the policy stated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 365423 Page 5 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

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** 5. Review of Resident #48's medical record revealed an admission date of 06/20/16. Diagnoses included acute kidney failure, actinic keratosis, muscle weakness, dysphagia oropharyngeal phase, anxiety disorder, paranoid schizophrenia, altered mental status, cough, shortness of breath and traumatic brain injury. Residents Affected - Some Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #48 had severe cognitive impairment and required two persons plus physical assistance for bathing. Review of Resident #48's electronic health record documented no exact days which were scheduled for showers. Review of the shower records dated January 2022 revealed showers were documented as completed on 01/01/22, 01/08/22, 01/09/22 and 01/16/22. Review of Resident #48's progress notes dated January 2022 revealed no documented evidence showers were refused. Interview on 01/24/22 at 11:59 A.M., a family member stated Resident #48 was supposed to receive showers on Monday, Wednesday and Friday mornings but showers had not been occurring on this schedule. Interview on 01/27/22 at 4:01 P.M., the Assistant Director of Nursing (ADON) #09 reported Resident #48 was scheduled for showers on Tuesdays and Fridays. The ADON #09 reported State Tested Nursing Assistants (STNAs) documented the showers in their charting and then placed information on the shower sheets. The ADON #09 denied having any shower sheets and was unable to verify findings due to a computer malfunction. The ADON #09 referred surveyor to STNA #51 who can assist with verifying findings of showers being given. Interview on 01/27/22 at 4:30 P.M., revealed STNA #51 reviewed shower sheets on the computer and verified Resident #48 has not been receiving showers as scheduled. This deficiency substantiates allegations in Master Complaint Number OH00129592. 4. Review of the medical record for resident #16 revealed an admission date of 08/18/21. Diagnoses included the need for assistance with personal care, age related physical debility. Review of the quarterly Minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required limited one person assistance with bathing and personal hygiene. Review of the resident's care plan dated 08/25/21 revealed Resident #16 had a self-care deficit related to confusion and limited mobility. Interventions included, provide sponge bath when a full bath or shower is refused or can not be tolerated. The resident required assistance by staff with bathing/showering. Review of the residents' shower/bath schedule revealed the resident was scheduled for showers/baths twice a week on Wednesday and Saturdays. Review of the Nurse Aide Bath Sheets dated from 12/22/21 through 1/22/22 revealed Resident #16 had received four showers on 12/22/21, 12/25/21, 01/12/22, and 01/22/22. On 01/25/22 at 12:15 P.M., during an interview the DON confirmed the resident was not receiving assistance with her showers as scheduled. 365423 Page 6 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/25/22 at 1:29 P.M., during an interview Resident #16 revealed she required assistance from staff to take showers. The resident stated she was scheduled for showers twice a week on Wednesdays and Saturdays and usually only gets one shower a week. Based on medical record review, staff, resident and family interview, observations, review of the staffing schedules for room assignments and policy review the facility failed to ensure residents received care and services according to the plan of care. This affected five residents (#09, #16, #37, #43 and #48) of six reviewed for activities of daily living (ADL). The facility census was 84. Findings include: 1. Medical record review for Resident #37 revealed an admission date of 09/01/2019. Diagnoses included stroke with hemiplegia and hemiparesis, contractures, communication deficit, hypertension, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 revealed impaired cognition. Resident #37 required extensive assistance for bed mobility and toilet use from one staff member, total assistance for transfers and supervision for eating. Resident #37 was assessed as always incontinent of bowel and bladder. Resident was last treated by physical therapy on 08/21/19. Review of the plan of care for revealed Resident #37 had an ADL self-care performance deficit related to activity intolerance, disease process (stroke), fatigue and paralysis on the left side. Interventions included two care givers at all times to provide care, the resident needed extensive assistance for turning and repositioning, was dependent for dressing, was dependent for eating, and the resident was checked four times per shift, change and give incontinence care as requested and needed. Resident #37 had bladder incontinence. Interventions included monitor and document signs and symptoms of urinary tract infections, check and change as needed, wash, rinse and dry perineum and change clothing as needed. Observation on 01/26/22 at 10:05 A.M. revealed Resident #37 was in bed with a red holiday shirt on and an incontinent brief. Resident was moving around in the bed repositioning a blanket around her. Resident #37's hair was uncombed, and she had food debris on her clothing. There was no splint in place on her left hand. The call light was attached to the left side rail. Observation on 01/26/22 at 12:15 P.M. revealed Resident #37 was in bed with the same red holiday shirt on, food debris remained on the shirt just under the shirt neckline. Resident #37 had an incontinent brief on and was moving extremities around a blanket in the bed. The call light was attached to the left side rail. Observation on 01/26/22 at 4:26 P.M. revealed Resident #37's lunch tray was on the floor in between the two beds occupying the room. The remaining food in the dishes was spilled out onto the floor. Cups were laying on the floor with liquids spilled onto the area. Resident #37 was observed wearing the same red holiday shirt. Additional food stains present on Resident #37's shirt in addition to the stains present just under the neckline from earlier observations. Observation on 01/26/22 at 4:28 P.M. of STNA #131 enter Resident #37's room and began to pick up food tray from floor. 365423 Page 7 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 01/26/22 at 4:31 P.M., with Licensed Practical Nurse (LPN) #130 stated she would have to check the schedule for sure as there were multiple schedule changes. LPN #130 stated State Tested Nursing Assistant (STNA) #131 was assigned to the room of Resident #37. LPN #130 stated she was last in the room to administer medication for Resident #37 at approximately 9:00 A.M. Interview on 1/26/22 at 4:44 P.M., in the room of Resident #37 the Agency STNA #131 stated she received the assignment for Resident #37 at 4:30 P.M. when she returned from her lunch break. She said this was the second notification of the schedule being changed. STNA #131 verified the resident was awake and had no splint device on. STNA #131 verified Resident #37 was wet through the incontinent pad, through the bed protector and on the sheet underneath her. STNA #131 stated she changed everything and washed up Resident #37. STNA #131 stated the facility changed the assignments all the time due to staff coming and leaving at nonscheduled hours. STNA #131 stated the supervisor gave her an assignment and she wrote it down on a piece of paper at 7:00 A.M., and on this assigned rooms had not included Resident #37's room. STNA #131 verified she had not provided Resident #37 with any care prior to this time. Interview on 01/26/22 at 4:59 P.M., with the Assistant Director of Nursing (ADON) #09 stated there seemed to be some confusion on STNA #131's assignment. The ADON #09 verified there was three different changes to the schedule. Interview on 01/26/22 at 5:04 P.M., with the Director of Nursing (DON) verified there was no documentation of toilet use, bathing, or meal consumption for Resident #37 in the electronic health record for 01/26/22. Interview on 01/26/2022 at 5:09 P.M., with STNA #54 who assisted with the care of Resident #37 stated the resident was incontinent of urine and stool. STNA #54 verified she removed the holiday shirt and it had food stains on the front of it. Interview on 01/26/22 at 5:28 P.M., with Agency STNA #133 stated she came in at 11:00 A.M. and was not assigned to Resident #37. STNA #133 verified she had not provided any care for Resident #37 during the day. STNA #133 stated the last schedule change occurred at approximately 11:00 when she arrived at the facility. Interview on 01/26/22 at 5:36 P.M. with Agency STNA #134 stated the room assignments had been changed at 8:00 A.M. when two scheduled STNA did not show up for work, another schedule change occurred at 11:00 when STNA #133 arrived at the facility. STNA #134 stated they started the day with six STNA scheduled and went to four at 8:00 A.M., then at 11:00 A.M. there was five STNA's. STNA #134 stated at 3:00 P.M. there was another schedule change and we had four STNA's on the second floor to care for sixty-three residents. STNA #134 verified that she had not provided any care for Resident #37 on 01/26/22. Interview on 01/26/22 at 5:47 P.M., with Agency STNA #135 at 5:47 P.M., verified she had not provided any care to Resident #37 at any time on her shift. Additionally stated staff got their assignment and had to change at approximately 8:00 A.M. because of staff not showing up. It happened a lot at this facility and we must check the assignment all the time because it changed so often. Review of the facility schedule dated 01/26/22, version one (shift 7:00 A.M. to 7:00 P.M.), revealed STNA #131 was not assigned to Resident #37. Further review of the schedules taped to the nursing station desk revealed version two (shift 7:00 A.M. to 7:00 P.M.) revealed STNA #131 was not assigned 365423 Page 8 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to Resident #37's room. Additional review of version three schedule located on the nursing station revealed STNA #131 was reassigned to Resident #37. There were no times located on the facility updated schedules where assignments were revised or added indicating when the schedule change was effective. 2. Medical record review for Resident #43 revealed an admission on [DATE]. Diagnoses included chronic kidney disease, dementia without behaviors, fracture of left femur, multiple fractures of ribs, acute respiratory failure, hypertension, epilepsy, hemiplegia, and hemiparesis following stroke, osteoarthritis of right hand, and esophageal obstruction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition. Resident #43 required extensive assistance for bed mobility, toilet use and transfers occurred only once or twice during the period. Resident #43 was able to eat with supervision. Resident #43 was always incontinent of bowel and bladder. No behaviors were documented on the assessment. Review of the plan of care for Resident #43 revealed resident has decreased activity of daily living (ADL) related to stroke with left sided hemiparesis, dementia, and decreased mobility. Interventions included staff extensive assistance for bed mobility, dressing, transfers and personal hygiene. Resident #43 was incontinent and wore disposable briefs. Interventions included monitor for sign and symptoms of infection, encourage fluids as tolerated, check resident four times per shift and as needed for incontinence, wash, rinse, and dry perineum and apply barrier cream as needed and change as needed. Observation on 01/26/22 at 10:05 A.M. revealed Resident #43 was asleep in bed wearing a hospital gown. Resident #43 had uncombed hair and food debris (crusts of bread) in her bed. There was no palm protector in place to her left hand. Observation on 01/26/22 at 12:15 P.M. revealed Resident #43 was in bed wearing a hospital gown, hair was uncombed and food debris (crusts of bread) remained in her bed. Observation on 01/26/22 at 4:26 P.M., revealed Resident #43's lunch tray was on the floor in between the two beds occupying the room. The remaining food in the dishes and spilled out onto the floor. Cups were laying on the floor with liquids spilled onto the area. Resident #43 was observed wearing a hospital gown and crusts of bread were in the bed. Interview on 1/26/22 at 4:44 P.M., in the room of Resident #43 the Agency STNA #131 stated she received the assignment for Resident #43 at 4:30 P.M. when she returned from her lunch break. She said this was the second notification of the schedule being changed. STNA #131 verified the resident was awake and had no palm protector on. STNA #131 verified Resident #43 was wet through the incontinent pad, through the bed protector and on the sheet underneath her. STNA #131 stated she changed everything and washed up Resident #43. STNA #131 stated the facility changed the assignments all the time due to staff coming and leaving at nonscheduled hours. STNA #131 stated the supervisor gave her an assignment and she wrote it down on a piece of paper at 7:00 A.M., and on this assigned rooms had not included Resident #43's room. STNA #131 verified she had not provided Resident #43 with any care prior to this time. Interview on 01/26/22 at 4:59 P.M. with the Assistant Director of Nursing (ADON) #09 stated there seems to be come confusion as to what STNA #131 assignment was. The ADON #09 verified there was three 365423 Page 9 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0677 different assignment changes to the schedule on 01/26/22. Level of Harm - Minimal harm or potential for actual harm Interview on 01/26/22 at 5:04 P.M. with the Director of Nursing (DON) verified there was not any documentation of toilet use, bathing, or meal consumption for Resident #43 in the electronic health record for 01/26/22. Residents Affected - Some Review of the facility schedule dated 01/26/22, version one (shift 7:00 A.M. to 7:00 P.M.), revealed STNA #131 was not assigned to Resident #43. Further review of the schedules taped to the nursing station desk revealed version two (shift 7:00 A.M. to 7:00 P.M.) revealed STNA #131 was not assigned to Resident #43. Additional review of version three schedule located on the nursing station revealed STNA #131 was reassigned to Resident #43. Review of the facility schedules revealed no documented time was added to any of the versions indicating when the schedule change was effective. Interview with Agency STNA #133 at 5:28 P.M. stated she came in at 11:00 A.M. and was not assigned to Resident #43. Further verified she had not provided any care for Resident #43 during her assigned shift on 01/26/22. STNA #133 stated the last schedule change occurred at approximately 11:00 A.M., when she arrived at the facility. Interview on 01/26/22 at 5:36 P.M. with Agency STNA #134 stated the room assignments had been changed at 8:00 A.M. when two scheduled STNA did not show up for work, another schedule change occurred at 11:00 when STNA #133 arrived at the facility. STNA #134 verified that she had not provided any care for Resident #43 on 01/26/22. Interview on 01/26/22 at 5:47 P.M., with Agency STNA #135 verified she had not provided any care to Resident #43 at any time during her shift on 01/26/22. 3. Review of the medical record for Resident #09 revealed a re-admission date of 08/24/21. Diagnoses included Parkinson's Disease, dysphagia, cardiac arrhythmia, sleep disorder not due to a substance or known physiological condition, cognitive communication deficit, hypertension, psychotic disorder with hallucinations due to known physiological condition, weakness, dementia in other diseases classified elsewhere without behavioral disturbance, other abnormalities of gait and mobility, orthostatic hypotension, major depressive disorder, and mixed hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 had severely impaired cognition. This resident required extensive assistance for bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Review of the plan of care dated 08/31/21 revealed Resident #09 required assistance with feeding at all meals. Interventions included allow adequate time for meals, reheat foods/fluids if necessary, ensure that the resident is sitting in a comfortable upright position for all meals, provide a clean environment, ensure bedside table is clean and at the appropriate height, sit down at eye level with the resident, explain you are going to help them eat their meal, and tell them what is on the plate for each meal. Observation on 01/27/22 at 12:13 P.M. revealed Resident #09 was observed eating lunch alone without any staff present. Interview on 01/27/22 at 12:14 P.M., with the Director of Nursing revealed Resident #09 required some assistance with eating but was not confident about the level of assistance she required. He 365423 Page 10 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0677 confirmed she was eating alone without the assistance from staff. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Assistance with Meals, revised 07/2017, revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents Affected - Some 365423 Page 11 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview and observations the facility failed to ensure residents received specialized range of motion appliances as ordered by the physician. This affected two residents (#43 and #37) of two residents reviewed for splints and palm protector placement. The facility census was 84. Residents Affected - Few Findings include: 1. Medical record review for Resident #37 revealed an admission on [DATE]. Diagnoses included stroke with hemiplegia and hemiparesis, contractures, communication deficit, hypertension, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 revealed impaired cognition. Resident #37 required extensive assistance for bed mobility and toilet use from one staff member, total assistance for transfers and supervision for eating. Resident #37 had functional limitations in range of motion on one side. Resident #37 was last treated by physical therapy on 08/21/19. Review of the plan of care for Resident #37 revealed resident had an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, disease process (stroke), fatigue and paralysis on the left side. Interventions include Resident #37 required two care givers at all times to provide care, resident needs extensive assist for turning and repositioning, dependent for dressing, dependent for eating, resident is not toileted, check four times per shift, check and change as needed, resident was to wear a hand roll, splint on the left hand for eight hours while sitting in a wheelchair to facilitate increased joint integrity. Review of the active physician's orders for Resident #37 revealed an order dated 08/21/19 for patient to wear hand roll splint on left hand for eight hours while sitting in wheelchair to facilitate increase joint integrity, nurse to check the skin for irritation. Review of the treatment administration record (TAR) for Resident #37 for the month of January 2022 revealed an order dated 08/21/19 for patient to wear hand roll splint on left hand for eight hours while sitting in wheelchair to facilitate increase joint integrity, nurse to check skin for irritation. The TAR revealed 01/26/22 was the only date signed off as completed by the nurse. Observation on 01/26/22 at 10:05 A.M. of Resident #37 revealed resident in bed with a red holiday shirt on and an incontinent brief. Resident was moving around in the bed repositioning a blanket around her. Resident #37 hair was uncombed, and she had food debris on her clothing. The splint was not in place on her left hand. Observation on 01/26/22 at 12:15 P.M. of Resident #37 revealed Resident #37 in bed with same red holiday shirt on, food debris remained on the shirt just under the shirt neckline. Resident #37 continued to have an incontinent brief on moving extremities around a blanket in bed. The splint was not in place. Interview on 1/26/22 at 4:44 P.M. Agency STNA #131 verified the splint was not in place and verified she was unable to locate the brace for Resident #37. 365423 Page 12 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/26/22 at 4:49 P.M. with Resident #37 stated no one has been in her room to care for her all day. Interview on 01/26/22 at 4:59 P.M. with the Assistant Director of Nursing (ADON) #09 stated staff is checking with laundry to see if the splint may have been sent to laundry. The ADON #09 verified Resident #37 did not have the splint on at this time. 2. Medical record review for Resident #43 revealed an admission on [DATE]. Diagnoses included chronic kidney disease, dementia without behaviors, fracture of left femur, multiple fractures of ribs, acute respiratory failure, hypertension, epilepsy, hemiplegia, and hemiparesis following stroke, osteoarthritis of right hand, and esophageal obstruction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition. Resident #43 required extensive assistance for bed mobility, toilet use and transfers occurred only once or twice during the look back period. Resident #43 was able to eat with supervision. Resident #43 had functional limitations in bilateral extremities. Review of the plan of care for Resident #43 dated 06/04/21 without revisions revealed resident has decreased activity of daily living (ADL) related to stroke with left sided hemiparesis, dementia, and decreased mobility. Interventions include staff extensive assistance for bed mobility, dressing, personal hygiene, transfers, personal hygiene, and resident to wear left palm protector daily when awake. Review of the physician orders for Resident #43 revealed an order dated 07/29/20 for patient to wear left palm protectors daily while awake, monitor for signs and symptoms of redness, and discomfort every shift. Review of the treatment administration record dated January 2022 for Resident #43 revealed an order for patient to wear left palm protectors daily while awake, monitor for signs and symptoms of redness, and discomfort every shift. Further review revealed 01/26/22 was the only date signed off as completed by the nurse. Observation on 01/26/22 at 10:05 A.M. of Resident #43 revealed resident in bed with hospital gown on. Resident was asleep. The palm protector was not in place to her left hand. Observation on 01/26/22 at 12:15 P.M. of Resident #43 revealed Resident #37 in bed, awake and no palm protector was in place on her left hand. Observation on 01/26/22 at 4:26 P.M. of Resident #43 revealed Resident #37 was in bed awake and no palm protector was in place on her left hand. Interview on 01/26/22 at 4:44 P.M. Agency STNA #131 verified the palm protector was not in place and she was unable to locate the palm protector for Resident #43 in her room. Interview on 01/26/22 at 4:59 P.M. with the ADON #09 stated staff was checking with laundry to see if the splint may have been sent to laundry. The ADON #09 verified Resident #43 did not have the palm protector on at this time and it was not available for application. 365423 Page 13 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, observation and review of the incident report the facility failed to ensure an intravenous (IV) catheter was initiated on the correct resident. This affected one resident (#50) of two residents reviewed for intravenous fluid. The facility census was 84. Residents Affected - Few Findings include: 1. Medical record review for Resident #50 revealed an admission date on 12/19/19. Diagnoses included hemiplegia and hemiparesis following a stroke, type two diabetes, high blood pressure, depression, and convulsions. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed intact cognition. Resident #50 required extensive assistance with bed mobility, toilet use and transfers occurred once or twice during the assessment period. Review of the plan of care for Resident #50 had no plan related for IV fluid administration. Review of the active physician's orders for the month of January 2022 had no orders for any IV fluid administration. Review of the multi-disciplinary progress notes for Resident #50 dated 12/06/21 through 01/09/22 had no documentation related to the insertion of an IV initiated in error. Interview on 01/27/22 at 10:45 A.M. with Resident #50 verified Registered Nurse (RN) #79 started an IV on 01/26/22. Resident #50 told the nurse that she had the wrong patient and he was told he was delusional and that happens when a person was dehydrated. Resident #50 stated they had fluid hanging with a machine that was attached to the IV at the time of the insertion. Resident #50 stated he was anxious because he was not sure what kind of medicine they were pumping into his belly. Resident #50 stated it was not long before the nurse returned to his room and removed the IV telling him it was for someone else down the hall. Observation on 01/27/22 at 10:50 A.M. of Resident #50's lower left abdominal area revealed a small red discoloration with a soft red scab. Observation on 01/27/22 at 10:58 A.M. of a beeping IV pump administering sodium Chloride 0.45 percent solution for Resident #31. Interview on 01/27/22 at 10:55 A.M. with the Assistant Director of Nursing (ADON) #09 verified the IV for the clysis solution was started on the wrong resident. The ADON #09 stated she had a call out to the nurse, RN #79 for investigational purposes. Interview on 01/27/22 at 1:50 P.M. with the Director of Nursing (DON) verified the IV was started on the wrong resident. Review of the facility incident report dated 01/26/22 at 7:00 A.M. revealed Resident #50 was accidentally stuck with a clysis needle. RN #79 failed to check if she was administering IV fluids to the right resident. The needle was pulled before the resident received any fluids. Two nurses stated he 365423 Page 14 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0694 had not received any fluids. Resident #50 statement revealed he was stuck with a needle for no reason. RN #79 was instructed to check orders before starting fluids on all residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365423 Page 15 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and observations the facility failed to monitor for adverse side effects for residents receiving psychotropic medications. This affected one resident (#57) of five residents reviewed for unnecessary medication. The facility census is 84. Residents Affected - Few Findings include: Medical record review for Resident #57 revealed an admission date on 01/01/20. Diagnoses included type two diabetes, metabolic encephalopathy, stage three kidney disease, dry eye syndrome, anxiety disorder, polyarthritis, depression, hypothyroidism, osteoporosis, history of mental and behavioral disorders. Review of the significant change Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed intact cognition. Resident #57 required extensive assistance for bed mobility, transfers, eating and toilet use. Resident #57 received antianxiety medication (two days out of seven days during the assessment period) and antipsychotic medications daily during the assessment period. Review of the plan of care for Resident #57 dated 12/06/21 revealed Resident #57 was at risk for exhibiting side effects of psychotropic medication related to the use of antipsychotic medication. Routine ability ordered for anxiety. Interventions include collaboration with hospice, monitor document and report as needed any adverse side effects, administer medication as ordered, consult with pharmacy to consider dose reduction when clinically appropriate, and discuss with physician, family the ongoing need for use of medication. Review of the active physician's orders for Resident #57 revealed an order for Ativan (antianxiety) tablet 0.5 milligrams (mg) give one tablet by mouth every 6 hours as needed for agitation/anxiety dated 12/11/21, Cymbalta capsule delayed release particles 20 mg (Antidepressant) give one capsule by mouth one time a day for depression dated 12/10/21, and Abilify (antipsychotic) tablet 10 mg give 10 mg by mouth one time a day for to use with Cymbalta for anxiety dated 02/18/21, Review of the medication administration record (MAR) for the month of November 2021, December 2021, and January 2022 for Resident #57 revealed no monitoring for adverse side effects related to the use of psychotropic medications. Review of the treatment administration record (TAR) for the month of January 2022 for Resident #57 revealed there was no monitoring for adverse side effects related to the use of psychotropic medications. Review of the progress notes for Resident #57 dated 11/16/21 through 01/31/22 had no documentation related to the monitoring for adverse side effects of psychotropic medications. Observation on 01/26/22 at 1:26 P.M. revealed resident was resting in bed with eyes closed without signs and symptoms of distress. Interview with Director of Nursing on 01/26/22 at 3:29 P.M. verified the facility was not monitoring for adverse side effects related to the administration of psychotropic medications and they should have been. 365423 Page 16 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and observations the facility failed to ensure residents receiving as needed psychotropic medications was limited to 14 days and not continued unless the prescribing physician evaluated the appropriateness of the medication. This affected one resident (#57) of five residents reviewed for unnecessary medication. The facility census is 84. Findings include: Medical record review for Resident #57 revealed an admission date on 01/01/20. Diagnoses included type two diabetes, metabolic encephalopathy, stage three kidney disease, dry eye syndrome, anxiety disorder, polyarthritis, depression, hypothyroidism, osteoporosis, history of mental and behavioral disorders. Review of the significant change Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required extensive assistance for bed mobility, transfers, eating and toilet use. Resident #57 received antianxiety medications during the assessment period. Review of the plan of care for Resident #57 dated 12/06/21 revealed resident was at risk for exhibiting side effects of psychotropic medication related to the use of antipsychotic medication. Routine ability ordered for anxiety. Interventions include collaboration with hospice, monitor document and report as needed any adverse side effects, administer medication as ordered, consult with pharmacy to consider dose reduction when clinically appropriate, and discuss with physician, family the ongoing need for use of medication. Review of the active physician's orders for Resident #57 revealed an order for Ativan tablet 0.5 MG (antianxiety) give one tablet by mouth every six hours as needed for Agitation/Anxiety dated 12/11/21. Review of the physician progress notes dated 12/13/21 had no documented specific condition regarding the use of Ativan, or the reevaluation of the medication to determine the need for the extended time frame. Review of the medication administration record (MAR) for the month of January 2022 for Resident #57 revealed Ativan 0.5 mg was administered on 01/02/22, 01/12/22, 01/13,22, 01/21/22 and 01/28/22. Review of the progress notes for Resident #57 dated 01/01/22 through 01/31/22 had no documentation related to the need/request for Ativan 0.5 mg related to agitation or anxiety. Review of the pharmacy recommendations for Resident #57, stored in the Director of Nursing's office, and not in the medical record dated 12/31/21 revealed Resident #57 currently had an order for Ativan every six hours as needed for anxiety/agitation. Request was made to the physician to evaluate the need for this order at this time and if considered necessary add a duration of 14 days. If considered appropriate to have a greater than 14 days, please document rational in the medical record and indicate the desired duration of the as needed order. Further review of the pharmacy recommendation revealed handwritten notes by an unidentified provider to add six months as she was hospice and 365423 Page 17 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0758 Level of Harm - Minimal harm or potential for actual harm needed for unpredictable/intermittent anxiety. Additionally, the provider had not dated the added documentation to the pharmacy request. Observation on 01/26/22 at 1:26 P.M. revealed resident was resting in bed with eyes closed without signs and symptoms of distress. Residents Affected - Few Interview with Director of Nursing on 01/26/22 at 3:24 P.M. verified the physician had not included a 14-day limit to Ativan initially. The DON further verified her monthly visit note did not include the rationale needed to support the extended time frame for the six-month duration of the Ativan's initial order. 365423 Page 18 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #58 revealed an admission on [DATE]. Diagnoses included heart failure, insomnia, hypertension, and hypothyroidism. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #58 had impaired cognition. Resident #58 required limited assist with bed mobility, and supervision for transfers, eating and toilet use. Review of the plan of care dated 11/19/21 for Resident #58 revealed resident has decreased cognition at times related to decreased communication and forgetfulness. Interventions include introduce self when entering the room, monitor for changes in cognition, administer medication as ordered. Review of the active physician's orders for Resident #58 had no orders for medications to be kept at bedside and there was no order for Tums antacid. Observation on 01/26/22 at 11:00 A.M. of Resident #58 room revealed a large bottle of tums antacids without a pharmacy label. Interview on 01/26/22 at 11:06 A.M. with Licensed Practical Nurse (LPN) #130 verified Resident #58 should not have medications in his room and did not have an order for Tums antacids. 4. Medical record review for resident #56 revealed an admission date on 08/23/16. Diagnoses included Chronic heart failure, chronic kidney disease, urinary tract infection, osteoarthritis of right shoulder, osteoarthritis, urinary incontinence, malignant neoplasm of left female breast, anemia, idiopathy pulmonary fibrosis, hyperlipidemia, Peripheral Vascular Disease, major depressive disorder shortness of breath. Review of the quarterly Minimum Data set (MDS) revealed Resident #56 had intact cognition. Resident #56 required extensive assist with bed mobility, dressing, toilet use, and personal hygiene. Review of the plan of care for Resident #56 dated 08/23/19 with revision on 06/21/21 revealed resident has shortness of breath and was now a patient of hospice due to congestive heart failure. Interventions include monitor and document breathing patterns, position resident for optimal breathing patterns, and monitor and report breathing abnormalities. Review of the active physician orders for Resident #56 revealed an order for Albuterol sulfate nebulization solution 0.63 milligrams per three milliliters. Observation on 01/24/22 at 12:03 P.M. of Resident #56 revealed a packet containing Albuterol sulfate nebulization solution 0.63 milligrams per three milliliters on the bedside table within reach of the resident. Interview on 01/24/22 at 12:25 P.M., with Registered Nurse (RN) #79 stated she left the medication in Resident #56's room that morning. RN #79 stated Resident #56 had no orders for medication to be kept at the bedside. 365423 Page 19 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Medical record review for Resident #08 revealed an admission on [DATE]. Diagnoses included malnutrition, dementia, Alzheimer's disease, and macular degeneration. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed Resident #08 had severely impaired cognition. Resident #08 required extensive assist for bed mobility, transfers, toilet use occurred only once or twice during the assessment period. Resident #08 received applications of ointments or medications to areas other than feet. Review of the plan of care for Resident #08 dated 02/07/2020 with revisions on 07/26/21 revealed resident has potential for pressure ulcer development related to disease process Alzheimer's dementia and history of pressure ulcers. Interventions include apply dressing and medications prophylactic to healed pressure areas per MD orders pressure reducing mattress and wheelchair cushions, administer treatments as ordered. Review of the active physician's orders for Resident #08 had no documented orders related to antifungal powder at the bedside. Observation on 01/24/22 at 12:34 P.M. revealed Resident #08 was sitting in a wheelchair in her room. Further observation revealed a bottle of antifungal powder with miconazole on a small dresser within reach of Resident #08. Interview on 01/24/22 at 12:44 P.M. with RN #79 revealed Resident #08 had no orders for antifungal powder and verified it should not be unsecured in the resident's room. Based on medical record review, observation, staff and resident interview and policy review. The facility failed to ensure medications were safely stored. This affected five residents (#08, #56, #58, #70 and #382) out of five residents reviewed. The facility census was 84. 1. Review of the medical record for Resident #70 he admitted to the facility on [DATE]. His diagnosis included essential primary hypertension, hyperlipidemia, anemia, arthritis, pressure ulcer of the left heel, and COVID-19. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 12/23/21 revealed he had intact cognition. Resident #70 was independent with eating and did not require any assistance from staff. Review of the Medication Administration Record (MAR) dated January 2022 revealed Resident #70 was ordered the following morning medications: ferrous sulfate (iron supplement) 365 mg , folic acid (a supplement) tablet one mg, lactobacillus (probiotic) capsule, senna (a medication for constipation) two tablets, thiamine (a vitamin supplement) HC1 Tablet 100 mg, tums (antacid) tablet 500mg, Vitamin D3 25 mcg 2 tablets, Zinc (supplement) tablet 50 mg, apixaban (a blood thinner) tablet 2.5 mg, Gabapentin (a nerve pain medication) 100 mg, metoprolol tartrate (antihypertensive medication) 25 mg, mucinex (expectorant) tablet 600 mg, Vitamin C tablet 500 mg, Dicyclomine HC1 (antispasmodic medication) 10 mg, and midodrine HC1 (treats low blood pressure) tablet five mg. Observation on 01/25/22 at 09:17 A.M. revealed Resident #70 was lying in bed and watching television with his overbed table across the bed. A medicine cup containing three pills was observed on the 365423 Page 20 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some over bed table. Resident #70 stated he was slow taking his morning medications because of the number of pills he was prescribed to take each morning. Resident #70 stated the three pills located in the cup on his bedside table were the remainder of his morning medications. Interview on 01/25/22 at 09:29 A.M. with Licensed Practical Nurse (LPN) #69 confirmed the pills in the medication cup at the bedside of Resident #70. LPN#69 stated the pills at the beside were apixaban 2.5mg and Vitamin D3 25 mcg three tablets. LPN#69 confirmed she failed to ensure Resident #70 consumed his morning medications. 2. Record review revealed Resident #382 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction, anemia, anemia, acute pulmonary edema, essential primary hypertension, acute embolism, chronic obstructive pulmonary disease, major depressive disorder, COVID-19, and cognitive communication deficit. Review of the MDS assessment dated [DATE] revealed Resident #382 was independent with eating and required no assistance from staff. Review of the MAR dated January 2022 revealed Resident #328 was ordered the following morning medications: amlodipine (high blood pressure medication) 5mg, duloxetine HCl (antidepressant medication) 30 mg, fluconazole (antifungal medication) 100 mg, folic acid (a supplement) two tablets, lactobacillus capsule, latanoprost (for glaucoma) emulsion 5% instill one drop in both eyes one time a day, oxybutynin (treats overactive bladder), magnesium oxide (a supplement) tablet 400mg, vitamin D3 25 mcg 2 tablets per day, zinc tablet 50 mg, ensure plus, ferrous sulfate 325 mg one tablet, pregabalin (treats nerve and muscle pain) 75 mg, and vitamin C 500 mg twp tablets. Observation on 01/24/22 at 12:17 P.M. observed Resident #382 lying in bed with oxygen on and watching television. Observed a bottle of eye drops on Resident #382's bedside table and next to the bottle of eye drops was a cup of what appeared to be a protein shake and a medicine cup with 10 pills inside. Interview on 11/24/22 at 12;30 P.M., with the Assistant Director of Nursing (ADON) #09 confirmed she left the cup bottle of eye drops and cup of multiple pills at the bedside of Resident #382. ADON#09 confirmed the medication left on the bedside table next to Resident #382 and failed to ensure they were administered. ADON#09 confirmed the eye drops latanoprost emulsion 5%), the ensure drink and the following pills were left on Resident #382's bedside table, Amlodipine 5mg, folic acid 2 tablets, vitamin c 500 mg 2 tablets, vitamin d3 25 mcg 2 tablets, zinc tablet 50 mg, pregabalin 75 mg, and oxybutynin. 365423 Page 21 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, and policy review the facility failed to ensure staff was available to assist dependent residents with eating after meals trays were delivered to resident rooms. This affected one resident (#36) of four reviewed for dependent residents requiring meal assistance. The facility census was 84. Residents Affected - Few Findings include: Medical record review for Resident #36 revealed an admission on [DATE]. Diagnoses included Alzheimer's disease, anxiety, hypertension, allergic rhinitis, gastroesophageal reflux disease, pulmonary fibrosis, stroke, malignant neoplasm of brain, major depressive disorder, malignant neoplasm of lungs, carcinoma of male genital organs and dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had impaired cognition. Resident #36 required extensive assistance from two staff members for bed mobility. Resident #36 required extensive assistance for eating from one staff member. Review of the plan of care for Resident #36 revealed the resident was at moderate nutritional risk due to diagnoses of weakness, dementia with diagnoses of Alzheimer's, hypertension pulmonary fibrosis and brain cancer. Resident fed self with set up assistance. Interventions include ensure pudding as ordered, Remeron (antidepressant) as ordered, monitor/document/report as needed any signs and symptoms of dysphagia, pocketing, chocking, coughing, drooling, holding in food in mouth and refusing to eat, weights as ordered, laboratory tests as ordered and administer medications as ordered. Review of the active physician orders for Resident #36 revealed an order for Remeron 15 mg by mouth at bedtime for mood and sleep dated 09/22/2020 and an order dated 09/22/20 for regular diet, pureed texture and nectar consistency liquids. Review of the electronic health record weights and vital signs tab revealed Resident #36 weight was 156.4 pounds on 01/12/22. Further review of weights revealed weight was 156.8 pounds on 12/01/21, the weight was 156.5 pounds on 11/17/21, and the weight was 148.1 pounds on 10/15/21. Review of the facility State Tested Nursing Assistant (STNA) documentation for Resident #36 revealed documentation dated on 01/15/22, 01/16/22, 01/21/22, 01/23/22, and 01/24/22 required extensive to total assist with meal consumption. Review of the facility's STNA document for Resident #36 revealed the resident ate between 25 percent to 100 percent of meals documented on 01/13/22, 01/15/22, 01/16/22, 01/24/22, and 01/25/22. Observation on 01/24/22 12:35 P.M. revealed Resident #36 had a covered meal tray sitting at the bedside without staff assisting the resident and out of reach of the resident. Continuous observation on 01/24/22 at 12:35 P.M. to 12:52 P.M. revealed Registered Nurse (RN) #79 entered Resident #36's room and began feeding resident. Resident #36 was not questioned regarding the appropriate food temperatures prior to eating. Observation on 01/24/22 at 12:58 P.M. Registered Dietician #129 checked the temperature of mashed 365423 Page 22 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0804 Level of Harm - Minimal harm or potential for actual harm potatoes revealed a temperature of 90 degrees Fahrenheit (F). The temperature of the pureed grilled cheese revealed a temperature of 80 degrees F. Registered Dietician verified the temperatures were too low stating they were not an at risk food. Registered Dietician #129 instructed RN #79 to reheat the food before continuing to feed resident. Residents Affected - Few 365423 Page 23 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review the facility failed to ensure a resident food preferences were accommodated. This affected one resident (#15) of three residents reviewed for meal preferences. The facility census was 84. Findings include: Review of Resident #15's medical record revealed an admission date of 11/17/21. Diagnoses included hypertensive heart disease without heart failure, insomnia, hypertension, anxiety, hearing loss, major depressive disorder, disorder of bone density and structure, hypothyroidism, atrial fibrillation and nonexudative age-related macular degeneration and bilateral, early dry stage. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. No rejection of care and the resident required supervision for eating. Observation on 01/24/22 at 12:22 P.M., revealed Resident #15's lunch meal was served and included a grilled cheese sandwich, tomato soup, potato chips, pickle chips, fruit cocktail and milk. Review of the dietary tray card revealed the resident had a standing order of eight ounces of hot chocolate. There was no hot chocolate on meal tray. Interview on 01/24/22 at 12:24 P.M., the State Tested Nursing Assistant (STNA) #85 reported Resident #15 was supposed to have hot chocolate with every meal. STNA #85 reported whom ever gave him his meal should have given him hot chocolate too as listed on the dietary tray card. STNA #85 verified there was no hot chocolate on his meal tray. Interviewed on 01/26/22 at 11:10 A.M., the Dietary Aide (DA) #39 reported standing orders means the food/drink item was required at every meal. Interviewed on 01/26/22 at 11:21 A.M., Diet Technician (DT) #86 verified standing orders are meal preferences and residents are supposed to have it served at every meal. Reviewed facility policy titled Mt. [NAME] Resident Food Preferences revised July 2017 revealed individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. 365423 Page 24 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview the facility failed to provide each resident with a therapeutic diet as ordered by their physician. This affected one resident (#54) of three residents reviewed for nutrition. Findings include: Review of Resident #54's medical record revealed the resident was admitted on [DATE]. Diagnoses included major depressive disorder, muscle weakness, unspecified dementia without behavioral disturbance, type two diabetes mellitus without complications, and gastro-esophageal reflux disease without esophagitis. Review of the quarterly minimum data set assessment (MDS) of the resident dated 12/16/21 revealed Resident #54 had severe cognitive impairment and required extensive assistance of one staff for bed mobility and transfer and required supervision for eating. No rejection of care noted. Review of the physician's orders revealed Resident #54 had an order for a Health Nutritional Shake (HNS) daily at lunch due to weight loss. Review of the resident's current comprehensive plan of care revealed a problem/need of being at nutritional risk. Interventions included to setup and assist with meals, and a HNS 120 milliliters (ml) once daily. Review of the monthly weights revealed Resident #54 had gradually added weight as ordered. Resident #54's weight was 153.2 pounds (lbs.) on 10/12/21 and on 01/13/22 he weighed 154.6 lbs. Resident #54 gained 1.4 lbs. in three months. Observation on 01/24/22 at 12:18 P.M., revealed Resident #54's lunch meal consisted of a grilled sandwich, tomato soup, potato chips, pickle chips, fruit cocktail and milk. Resident #54 was eating his meal. There was no HNS located on the tray. Observation on 01/24/22 at 12:22 P.M., revealed Resident #54's lunch meal ticket had standing orders of four fluid ounces of HNS. Resident #54 did not have the HNS with his lunch meal. Interview on 01/24/22 at 12:24 P.M., the State Tested Nursing Assistant (STNA) #85 reported Resident #54 was supposed to have four fluid ounces of the HNS with the lunch meal. STNA #85 gave Resident #54 a Health Nutritional Shake and verified it was not on the tray. Interviewed on 01/26/22 at 11:10 A.M., the Dietary Aide (DA) #39 reported standing orders means the food/liquid was required at every meal. Interview on 01/26/22 at 11:21 A.M., the Diet Technician (DT) #86 confirmed a physician order for Resident #54 to have Health Nutritional Shake with every meal. The order was written 10/27/21. DT #86 reported, It was a dietary error due to the dietary aides are responsible for plating from the meal ticket. DT #86 reported dietary services are down in numbers with six workers out including the dietary manager. She added the department had been pulling employees from other departments to assist 365423 Page 25 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0808 in dietary. Level of Harm - Minimal harm or potential for actual harm This deficiency substantiates Complaint Number OH00129099. Residents Affected - Few 365423 Page 26 of 27 365423 02/04/2022 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and policy review the facility failed to ensure refrigerator temperatures were checked routinely, specifically refrigerators holding medications. Additionally, failed to ensure residents' refrigerated foods were properly labeled. This affected all 84 residents who reside in the facility. The facility census was 84. Findings include: Observation on 01/27/22 at 9:24 A.M., revealed medicine storage room refrigerator on first floor had no monthly temperature log. Two thermometers were in the refrigerator with prescribed medications. The temperature in the refrigerator was appropriate at this time, but no monthly temperature log was present. Interview on 01/27/22 at 9:35 P.M., revealed Licensed Practical Nurse (LPN) #85 reported she was not sure who was responsible for keeping medicine refrigerator temperatures and had no knowledge of monthly temperature log sheet. LPN #85 verified there was no monthly temperature log to document daily temperatures. Observation on 01/27/22 at 10:34 A.M., revealed the second floor medicine storage revealed the monthly temperature log had four dates noted on 01/01/22, 01/08/22, 01/09/22 and 01/15/22. There were three [NAME] Light beers with no name and a box of Stouffers Chicken Fettuccine and Meat Loaf Classic with a resident's name listed but no date. Interview on 01/27/22 at 10:50 A.M., revealed Registered Nurse (RN) #09, reported night shift nursing supervisors are responsible for cleaning out the refrigerators. RN #09 also reported both shift supervisors are responsible for making sure monthly temperature logs are filled out daily. Review of facility policy titled Mt [NAME] Policy for Foods Brought by Family/Visitors, dated 09/06/17 revealed foods that must be kept under refrigeration must be labeled with the resident's name, room number and date. Food items will be stored in the refrigerator. Foods will be discarded after 72 hours. This deficiency substantiates Complaint Number OH00129093. 365423 Page 27 of 27