Health inspection·January 5, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with the physician, and review of the facility policy, the facility failed to timely notify the physician when Resident #78 had abnormal vital signs during the time Resident #78 was exhibiting a change in condition and being treated for an infection. This affected one (Resident #78) of three residents reviewed for change in condition. Findings include: Review of the medical record revealed Resident #78 was re-admitted to the facility on [DATE]. Diagnoses included cholecystitis, severe protein-calorie malnutrition, vascular dementia, and urine retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was severely cognitively impaired. Review of the plan of care dated 11/21/23 revealed Resident #78 was at risk for activity of daily living and self-care performance deficit related to intolerance, dementia, and fatigue. Interventions included to obtain and record all vital signs per orders and as needed, and report changes from usual to physician. Review of the progress note dated 11/29/23 documented by Unit Manager (UM) #225 revealed at 4:00 P.M., the resident's temperature was 101.3 Fahrenheit (F). The physician was notified to have new order to obtain STAT complete blood count (CBC), basic metabolic panel (BMP), UA and culture and sensitivity if indicated. Rocephin one gram intramuscular (IM) every day for seven days for fever/urinary tract infection. The progress note dated 11/29/23 documented by UM #225 revealed a new order to obtain for vital signs every shift while on antibiotic therapy. Review of the vital signs for Resident #78 revealed the following the resident's oxygen saturation on 11/29/23 at 9:40 A.M. was 92% on room air; on 11/30/23 at 7:15 A.M. was 91% on room air; on 11/30/23 at 5:51 P.M. was 90% on room air; and on 12/01/23 at 6:53 A.M. was 91% on room air. Further review of the medical record revealed the physician was not made aware of Resident #78's oxygen saturations being 90 and 91 on 11/30/23. There was no physician orders for supplement oxygen and no notes that supplemental oxygen was administered to Resident #78. Review of the progress note dated 12/01/23 at 10:30 A.M. revealed Resident #78 was not responding to sternum rub, calling resident by name, increase respirations 48, blood pressure 93/64, oxygen saturation was 86% room air, temperature was 99.5, and Resident #78 slightly opening his eyes. LPN #227 sent a message to physician with new orders to send to emergency room. The progress note dated Page 1 of 7 365423 365423 01/05/2024 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/01/23 revealed the hospital notified the facility that Resident #78 was admitted to the hospital with septic shock. Interview on 01/04/24 at 12:52 P.M. with Medical Director #440 stated UM #225 had called her and gave her information about Resident #78 and was not eating, or drinking, and had lethargy on 11/29/23. MD #440 stated she wanted the facility to push fluids. MD #440 stated she did not get notified on 11/30/23 when Resident #78's oxygen saturation was 90-91% room air. MD #440 said oxygen supplementation would have been ordered for Resident #78. MD #440 stated she expected the facility staff to notify her of abnormal vital signs. Review of the facility policy titled Notification of Changes, dated 2023, revealed the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician, and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00148872. 365423 Page 2 of 7 365423 01/05/2024 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's policy, the facility failed to investigate resident falls and determine the root cause of the resident's falls. This affected three (#25, #82, and #86) of three residents reviewed for falls. The facility census was 82. Findings include: 1. Review of the closed medical record revealed Resident #86 had an admission date on [DATE]. Resident #86 discharged from the facility on [DATE]. Diagnoses included hypertension and systolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was moderately cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #86 was at risk for falls related to confusion, gait and balance problems, hypotension, poor communication, and comprehension and unawareness of safety needs. Interventions included non-skid socks as tolerated and ensure the resident was wearing appropriate non-skids in bed. Review of the fall risk tool dated [DATE] revealed Resident #86 was at a high fall risk with the score of 16.0. Resident #86 had daily incontinence and needed assistance, had a wheelchair with balance issues, and needed transfer assistance. Review of the facility's fall and incident log dated from [DATE] through [DATE] revealed Resident #86 fell on [DATE] and [DATE]. Interview on [DATE] at 4:40 P.M. with the Director of Nursing (DON) verified there was no fall investigation or root cause analysis for Resident #86's falls on [DATE] and [DATE]. 2. Review of the closed medical record for Resident #82 revealed an admission date [DATE]. Resident #82 expired in the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, vascular dementia with severe agitation, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was severely cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #82 was at risk for falls related to confusion and gait and balance problems. Interventions included personal items within reach, call light in reach, encourage activities, follow fall protocol, continue interventions on the at-risk plan, declutter room, encourager resident to be out of bed, collaborate with hospice, and medication review as needed. Review of the fall risk tool dated [DATE] revealed Resident #82 had a score of 14 which indicated the resident was at a high risk for falling. Resident #82 had moderate vision impairment, cognitive level was severely impaired, and had a wheelchair with balances issues and needing transfer assistance. Review of the fall and incident log dated from [DATE] through [DATE] revealed Resident #82 fell on [DATE], [DATE], [DATE], and [DATE]. 365423 Page 3 of 7 365423 01/05/2024 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 4:40 P.M. with the Director of Nursing (DON) verified there was no fall investigation or root cause analysis for Resident #82's falls on [DATE], [DATE], [DATE], and [DATE]. 3. Review of the medical record for Resident #25 revealed an admission date [DATE]. Diagnoses included adult failure to thrive, disorder of bladder, type two diabetes mellitus, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #25 was at risk for falling related to decreased mobility, decreased cognition, decreased communication and resident fell out of wheelchair related to having pillow in seat on [DATE]. Interventions included dycem in wheelchair, offer to assist with toileting, bed to be in lowest position, keep resident in common area while up in wheelchair, monitor wheelchair for pillows, offer to assist with toileting after meals, visual signs in room to call for help with transfers, anticipate resident's needs, ensure the resident was wearing non-skid footwear, and call light in reach. Review of the fall risk tool dated [DATE] revealed Resident #25 had a fall score of 21 which indicated the resident was at a high risk for falling. Resident #25 had moderate vision impairment, cognitively moderately impaired and not following safety needs, and daily incontinence. Review of the fall and incident log dated from [DATE] through [DATE] revealed Resident #25 fell on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 4:40 P.M. with the Director of Nursing (DON) verified there was no fall investigation or root cause analysis for Resident #25's falls on [DATE], [DATE], and [DATE]. Review of the facility policy titled Falls-Clinical Protocol, dated 03/2018, revealed the physician will help identify individuals with history of falls and risk factors for falling. Nurse shall assess, perform vitals, document, and report injury, observe for change in condition or level of consciousness, neurological status, pain, frequency, and number of falls since last physician visit, precipitating factors on details how fall occurred, all current medications and active diagnosis. This deficiency represents non-compliance investigated under Complaint Number OH00149067 and Complaint Number OH00149419. 365423 Page 4 of 7 365423 01/05/2024 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, observation, record review, and review of the facility policy, the facility failed to provide timely incontinence care for a resident. This affected one (Resident #80) of three residents reviewed for incontinence care. The facility census was 82. Findings include: Review of Resident #80's medical record revealed an admission date of 12/10/21. Diagnoses included dementia severity, anxiety disorder, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was severely cognitively impaired. Resident #80 required substantial maximum assistance from staff for toileting. Review of the plan of care dated 12/01/23 revealed Resident #80 was at risk for incontinence and wearing disposable briefs, required and received assistance with toileting and incontinence care, and was at increased risk for skin breakdown and urinary tract infections. Interventions included to monitor and document signs and symptoms of urinary tract infection and to notify the physician of symptoms burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urine odor, change in behaviors, and change in eating problems. Staff to check four times for incontinence per shift and as required for incontinence, wash and rinse perineum. Apply barrier cream. Change clothing as needed after incontinence episodes. Observation on 01/02/24 at 3:35 P.M. revealed Nurse Aide (NA) #802 and NA #444 laid Resident #80 down in her bed and began to provide incontinence care to Resident #80. Resident #80 had a large wet stain on her bottom through her pants. Resident #80 had a incontinent brief on that had an odor, severely saturated in urine with bowel movement up the front in peri area. Resident #80 had redness all on peri area, leg creases, and bottom. Interview on 01/02/24 at 3:45 P.M. with NA #444 confirmed the large wet spot-on Residents #80 pants, odor, severe urine saturation, and bowel movement that was encrusted in the peri area. NA #444 and NA #802 confirmed Resident #80 was not their assignment for that day (01/02/24) and they did not provide incontinence care during their shift until 3:35 P.M. NA #444 stated they were told to help NA #399 because she was trying to give care to other residents on her floor. Interview on 01/02/24 at 3:48 P.M. with Licensed Practical Nurse (LPN) #227 verified Resident #80's skin on her bottom, peri area, and leg creases were red. Interview on 01/02/24 at 3:50 P.M. with NA #602 stated she did not check and change Resident #80 because the resident was not on her assignment for that day (01/02/24). Interview on 01/02/24 at 4:00 P.M. with NA #399 stated her original assignment was to be the shower aide but got pulled to the floor to work as a nurse aide. NA #399 verified she did not provide incontinence care to Resident #80 that day (01/02/24). NA #399 stated Resident #80 was already up and dressed for the day when she began her shift at 8:00 A.M. Interviews on 01/02/24 at 4:05 P.M. with NA #204, at 4:10 P.M. with NA #44, at 4:15 P.M. with NA 365423 Page 5 of 7 365423 01/05/2024 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0690 Level of Harm - Minimal harm or potential for actual harm #815, and at 4:43 P.M. with NA #305 stated they did not change or provide incontinence care to Resident #80. Interview on 01/02/24 at 4:35 P.M. with NA #300 stated she had dressed and provided care to Resident #80 at 6:20 A.M. this morning (01/02/24) before she left at 7:00 A.M. Residents Affected - Few Subsequent review of the wound physician progress note and physician orders dated 01/02/24 revealed Wound Nurse Practitioner (WNP) #311 stated Resident #80 was assessed today due to skin issue. Resident #80 seen as nurse request of report of redness to buttocks area. WNP #311 stated incontinence associated dermatitis. WNP #311 stated to start Calmoseptine cream to be applied after periods of incontinence every shift and as needed every shift for blanchable redness. The physician order dated 01/02/24 revealed Resident #80 had an order for Calmoseptine cream applied after periods of incontinence every shift and as needed. Review of the facility policy titled Activities of Daily Living, Supporting, dated 03/2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out the activity of daily living independently. This deficiency represents non-compliance investigated under Complaint Number OH00148872 and Complaint Number OH00149419. 365423 Page 6 of 7 365423 01/05/2024 Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Potential for minimal harm Based on staff interview and record review, the facility failed to have a full time qualified social worker for a facility with more than 120 beds. This had the potential to affect all 82 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility's demographics revealed the facility was certified for 129 beds. Review of the former social worker's employee file revealed the Director of Social Services #575 last day worked was 11/21/23. Interview on 01/02/24 at 10:56 A.M. with the Director of Nursing (DON) verified the facility did not have a full time qualified social worker. The DON stated the current Administrator was off on personal leave and unable to be reached. This deficiency represents non-compliance investigated under Complaint Number OH00149067. 365423 Page 7 of 7