Health inspection·March 30, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interviews and policy review, the facility failed to ensure a resident was treated with respect and dignity during resident care. This affected one (#48) of three residents reviewed for dignity and respect. The facility census was 100. Findings included: Review of Resident #48's medical record revealed an admission date of 01/28/19, with diagnoses including nontraumatic intracerebral hemorrhage, deep vein thrombosis, diabetes and obesity. Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively intact. Resident #48 functional status was extensive assistance with two-person assistance with bed mobility and toilet use. Resident #48 was frequently incontinent of bowel and bladder. Review of the care plan dated 01/05/23 revealed Resident #48 was at risk for bowel and bladder incontinence related to impaired mobility. Interview with Resident #48 on 03/28/23 at 11:45 A.M., reported he has urgency and will go a lot when he urinates. Resident #48 revealed staff put towels into his depends due to leakage and not wanting to change the linens. Resident #48 stated he thought this was standard of care, but it causes redness and itchiness and reported he bleeds under the genital area. Observation on 03/28/23 at 3:14 P.M., revealed Licensed Practical Nurse (LPN) #169 helped Resident #48 with the urinal. A white rolled up towel was observed in Resident #48's brief. Resident #48 was without excoriation in the groin area. LPN #169 stated there was towel in the brief. LPN #169 then proceeded to say to Resident #48, tell the surveyor the truth about the towel and that you ask the aides for the towel to be placed in your brief. Resident #48 appeared to be very surprised by the comment made to him by LPN #169 and didn't answer. Interview on 03/29/23 at 8:43 A.M., with Resident #48 stated he was embarrassed and humiliated by what the LPN #169 said to him during the observation on 03/28/23 at 3:14 P.M. Resident #48 stated he felt it was a matter of dignity and respect the way LPN #169 treated him in front of the surveyor. Interview on 03/29/23 at 10:05 A.M., with LPN #169 stated she called out Resident #48 about the towel in the brief because she felt like Resident #48 was going to tell the surveyor, he didn't want the towel in his brief and LPN #169 wanted Resident #48 to tell the truth. Page 1 of 25 365514 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the undated policy titled Dignity and Respect, revealed dignity was defined as a state worthy of honor or respect; includes but not limited to speaking respectfully to resident, and respecting resident choice. Residents will be treated with dignity and respect. When the staff provide care the staff will speak respectfully to the resident. Residents Affected - Few 365514 Page 2 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview and policy review, the facility failed to ensure residents and resident representatives were offered the opportunity to participate in care planning. This affected two (#31 and #60) of two residents reviewed for care conferences. Facility census was 100. Findings include 1. Review of the medical record for the Resident #31 revealed an admission date of 01/21/13. Diagnoses included diabetes, convulsions, dementia, contractures of bilateral knees, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact and was independent with mobility. Review of the medical record revealed no evidence of a care conference being held during the second quarter of 2022. Interview on 03/29/23 at 4:55 P.M., with the Director of Nursing (DON) verified there was no evidence of a care conference being held in the second quarter of 2022. 2. Medical record review for Resident #60 revealed an admission date of 03/13/20. Medical diagnoses included atrial fibrillation, peripheral vascular disease, and cirrhosis. Review of annual MDS dated [DATE] revealed Resident #60 was cognitively intact. His functional status was limited assistance with bed mobility, transfers, and toileting. He was independent for eating. Review of care conferences for Resident #60 revealed he received one on 07/07/22 and 01/18/23 and only MDS #200 was in attendance. Interview with Resident #60 on 03/28/23 at 8:17 A.M., revealed he was not receiving care conferences. Interview on 03/30/23 at 9:35 A.M., with MDS Nurse #186 and MDS Nurse #200 revealed care conferences should be held upon admission and quarterly thereafter. They revealed residents and families are invited to attend and staff from each department should attend. Due to staff turnover and not having management in many areas, MDS Nurse #186 revealed after the meetings they inform the individual departments of any concerns and they should follow up on the concerns. Review of undated policy titled, Plan of Care Overview: Care Conferences, revealed residents and resident representatives have the right to participate in the development and implementation of the care plan with rights to have meetings. An interdisciplinary care team participates in planning and implementation of care may include clinical team (licensed and non-licensed), therapy team, social services, activities, dietary team, medical providers, business team, administration team, family and resident. Attendees will sign and date care plan meeting documents. 365514 Page 3 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews and medical record review, the facility failed to ensure a resident was assessed for self-administration of medication. This affected one (#41) of 26 residents observed in the sample. The facility census was 100. Residents Affected - Few Findings include: Review of the medical record for Resident #41 revealed an admission date of 12/28/17. Diagnoses included chronic obstructive pulmonary disease, aortic aneurysm, poly neuropathy, dysphagia, and pneumonia. Review of the Self Administration of Medication assessment dated [DATE] revealed Resident #41 required assistance with ear drops, suppositories and subcutaneous injections. Resident #41 had no recent assessments for self-administration of medication. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact and was independent with mobility. Review of the plan of care dated 03/30/23 revealed Resident #41 did not have a care plan entry related to medication self-administration prior to the survey findings. On 03/30/23, facility updated the care plan to include that Resident #41 prefers to self-administer his medication. Resident completed education regarding medication administration. Review of the March 2023 monthly physician orders revealed orders for pantoprazole sodium oral tablet delayed release 20 milligrams (mg) two tablets; gabapentin oral capsule 400 mg, one tablet; folic acid oral tablet 1mg one tablet; ferrous gluconate oral tablet 324 mg one tablet; acetaminophen oral tablet 500 mg two tablets and potassium chloride extended release tablet 10 milliequivalents for two tablets. Interview and observation on 03/27/23 at 10:30 A.M., with Resident #41 revealed the resident had a cup of pills on his bedside table. Resident #41 reported he had eight to nine pills but declined allowing surveyor to look into the cup to count them. Resident #41 named some of the pills in the medication pass cup including protonic, iron, and Symbicort. Interview and observation on 03/27/23 at 10:38 A.M., with Licensed Practical Nurse (LPN) #178 confirmed pills were left at bedside, as the resident like us to leave them. LPN #178 revealed resident was not approved to self-administer medications. When LPN #178 entered room to confirm resident was shouting at LPN#178 and did not want staff watching him. Interview on 03/29/23 at 4:00 P.M., with the Director of Nursing (DON) #124 revealed Resident #41was not able to self-administer and had not recently been assessed or approved to self-administer his medications. DON revealed no facility residents had been approved to self-administer medication. Review of the undated policy titled, Medication Administration, revealed medication should never be left unattended, staff should remain with resident until medication are swallowed, and staff should not leave medication at bedside. 365514 Page 4 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of resident council minutes, staff and resident interviews and policy review, the facility failed to ensure resident council concerns were addressed in a timely manner. The facility also failed to ensure residents were knowledgeable on how to file a complaint with the state or contact the Ombudsman. This affected three (#31, #36, #20) of 10 residents that regularly attend the resident council, with the potential to affect the 10 residents. The facility census was 100. Residents Affected - Some Findings included: Review of the resident council meeting minutes from 06/28/22 through 02/23/23 revealed there wasn't any education given to the residents about contacting the state agency about a complaint about their care, or how to contact the ombudsman regarding any issues they may have. All of the minutes said to place concerns on concern forms and distribute to appropriate department heads. There was various concerns brought up for different departments. There was no resolution forms or areas of corrections forms related to the concerns brought up by residents. Interviews on 03/30/23 at 11:33 A.M., with Resident #31, #36 and #20 during a resident group meeting revealed they didn't feel like the facility gets back to them in a timely manner or at all about the things that are brought up in resident council. When asked the residents stated they did not know how to file a complaint with the state or to get in contact with the Ombudsman. Interview with the Administrator on 03/30/23 at 12:06 P.M., revealed he couldn't speak to what happened before he started at the facility about three months ago. When he came to the facility he instructed the residents if they had any concerns in resident council to file a grievance and the facility would follow up with the concerns. there has only been one filed by the residents and that was for wandering of the residents which was resolved on 12/12/22. He stated he didn't know how to rectify getting in touch with the residents about how to contact the Ombudsman and reporting to the state. The Administrator stated he could go around to each room and let the resident know how to get in contact with them. The Administrator confirmed since he had been at the facility, the residents have not been educated on contacting the ombudsman or state agency with concerns. Review of the policy titled Resident Council dated 04/22/21, revealed it is the expectation the Administrator offer to attend the Resident Council Group Meeting. While it is the residents' choice to have staff in attendance, Administration should ask permission to attend (even for a short appearance) to assure residents that all grievances and concerns are as important to the management team as they are to the resident. Any concerns during the Resident Council Meeting should be documented on the Resident Council Minutes Form. Any concerns voiced at the meeting should be documented on the concern form and distributed to the appropriate department head. 365514 Page 5 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to issue the CMS -20052 form to indicate skilled coverage was ending. This affected two (#35 and #26) of three residents who exhausted their Medicare Part A Skilled Services. The facility census was 100. Residents Affected - Few Findings include: Review of Resident #206's (Skilled Nursing Facility) SNF Beneficiary Protection Notification Review revealed the last day covered was 12/08/22 the Resident discharged on 12/09/23. The Form CMS-20052 was not issued 48 hours prior to the resident's last day of coverage. Review of Resident #38's SNF Beneficiary Protection Notification Review revealed his last day of coverage was 03/23/22 and Resident #38 went home on 3/24/23. The Form CMS-20052 was no issued 48 hours prior to the resident's last day of coverage . Interview on 03/28/23 at 10:00 A.M., with Registered Nurse (RN) #200 verified she did not issue the Form CMS-20052 was no issued 48 hours prior to the resident's last day of coverage because the residents decided to be discharged . 365514 Page 6 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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 observations, resident and staff interviews, the facility failed to ensure a resident's room was provided a room in a home like environment by not utilizing the resident's room for facility storage. The affected one (#18) of six residents reviewed for environment. The facility census was 100. Findings include: Interview on 03/27/23 at 9:30 A.M., with Resident #18 revealed there was items stored in his room that was not his and he keeps his curtain pulled. Observation on 03/27/23 at 9:30 A.M., 03/28/23 at 5:27 P.M., and on 03/29/23 at 4:51 P.M., of Resident #18's room revealed the room was a two person room. Resident #18 resided in B bed with his curtain drawn. There was no accommodations for a roommate, because there was no bed A in the room. The space for bed A was being utilized as storage for the facility. Two large floor polishing machines, two Hoyer (mechanical) lifts, an extra wide wheelchair that does not belong to Resident #18 and various boxes were being stored in Resident #18's room Observation on 03/28/23 at 5:27 P.M., revealed Resident #18 had his curtain drawn and the storage of facility equipment was still on the bed A side. Interview on 03/29/23 at 4:51 P.M., with Register Nurse (RN) #153 confirmed the items in the bed A area should not be in Resident #18's room. Interview on 03/30/23 at 9:00 A.M, with the Administrator revealed Resident #18 room is not a private room and he was unaware there wasn't a bed A. The Administrator confirmed the area should not be utilized for storage. 365514 Page 7 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of policy, and staff interview, the facility failed to notify residents or resident representatives of facility policy for bed holds, to include amount of bed hold days used and left and potential cost liability. This affected two (#54 and #86) of three residents reviewed for hospitalization. The census was 100. Findings include: 1. Medical record review for Resident #54 revealed admission date 12/13/22. Diagnoses including diabetes mellitus 2 (DM2), chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity, chronic obstructive pulmonary disease (COPD), heart failure, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. The MDS data revealed Resident #54 discharged with return anticipated on 12/23/22 and returned 12/28/22. Interview on 03/20/23 at 11:39 A.M., the Director of Nursing (DON) stated she was not able to locate any Bed Hold documentation for Resident #54. 2. Medical record review for Resident #86 revealed admission date 01/08/23. Diagnoses including sepsis, acquired absence of left great toe, displaced intertrochanteric, fracture left femur, routine healing, Diabetes Mellitus (DM2), polyneuropathy, chronic atrial fibrillation (A fib), hypertension (HTN), pressure ulcer sacral region Stage three, laceration left lower leg, cardiac pacemaker, wedge fracture fifth lumbar vertebra, and glaucoma. Review of the admission MDS assessment dated [DATE] revealed Resident #86 had intact cognition. Review of the MDS data revealed Resident #86 discharged return anticipated on 02/13/23 and returned 02/22/23. Review if the Notification Note date 02/15/23 revealed resident was notified he is on a paid bed hold while at the hospital and can return when medically ready. Interview on 03/20/23 at 11:39 A.M., the DON stated she was not able to locate additional Bed Hold documentation for Resident #86. Review of the undated policy titled Bed Hold Policy, revealed it is the intent of this facility to obtain the proper authorization to hold a resident bed when the resident returns to the hospital or goes on leave. The bed hold authorization form may be signed prior to the patient leaving the building, or with 24 hours of the resident leaving the facility or the following business day if the resident leaves on the weekend or holiday. The Admissions Director or designee will notify the resident and/or responsible party of the days available under their Medicaid benefits or the private party cost associated with holding the bed will be explained, within 24 hours of the patient leaving the facility, or the following business day if the patient leaves on the weekend or a holiday. The business office manager or designee will follow all state specific guidelines upon resident return regarding notifying resident or responsible party of amount of bed hold days used and left. 365514 Page 8 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview and policy review, facility failed to ensure members of the interdisciplinary team (IDT) with the resident and/or resident representative reviewed and revised care plans at least quarterly. This affected two (#31 and #60) of two residents reviewed for care conferences. The facility census was 100. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 01/21/13. Diagnoses included diabetes, convulsions, dementia, contractures of bilateral knees, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact and was independent with mobility. Review of the medical record revealed there was no evidence of a care plan conference being held or the IDT reviewing the care plan during the second quarter of 2022. Review of the progress notes dated 07/21/22 revealed a care conference was held and the MDS Nurse #200 was the only staff member in attendance. Review of Care conference form dated 07/21/22 revealed only a MDS staff conducted a care conference. Review of Care conference form dated 11/03/22 revealed only a MDS staff conducted a care conference. Review of the progress notes dated 01/25/23 revealed a care conference was held and the MDS Nurse #200 was the only staff member in attendance. Interview on 03/29/23 at 4:55 P.M., with DON #124 revealed interdisciplinary care conferences should include members of the interdisciplinary teams. DON revealed staff from each department should attend the care conference meetings. The DON revealed facility has been without a social worker for about 18 months and the MDS coordinator has been filling in for care conference meetings. Interview on 03/30/23 at 9:35 A.M. with MDS Nurse #186 and MDS Nurse #200 revealed care conferences should be held upon admission and quarterly thereafter. They revealed residents and families are invited to attend and staff from each department should attend. Due to staff turnover and not having management in many areas, MDS Nurse #186 revealed after the meetings they inform the individual departments of any concerns, and they should follow up on the concerns. 2. Medical record review for Resident #60 revealed an admission date of 03/13/20. Medical diagnoses included atrial fibrillation, peripheral vascular disease, and cirrhosis. Review of annual MDS dated [DATE] revealed Resident #60 was cognitively intact. His functional status was limited assistance with bed mobility, transfers, and toileting. He was independent for eating. 365514 Page 9 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of care conferences for Resident #60 revealed he received a conference on 07/07/22 and 01/18/23 and only MDS staff #200 was in attendance. Interview with Resident #60 on 03/28/23 at 8:17 A.M., revealed he was not receiving care conferences. Interview on 03/29/23 at 4:55 P.M., with the Director of Nursing (DON) #124 revealed interdisciplinary care conferences should include members of the interdisciplinary teams. DON revealed staff from each department should attend the care conference meetings. The DON revealed facility has been without a social worker for about 18 months and the MDS coordinator has been filling in for care conference meetings. Interview on 03/30/23 at 9:35 A.M., with MDS Nurse #186 and MDS Nurse #200 revealed care conferences should be held upon admission and quarterly thereafter. They revealed residents and families are invited to attend and staff from each department should attend. Due to staff turnover and not having management in many areas, MDS Nurse #186 revealed after the meetings they inform the individual departments of any concerns, and they should follow up on the concerns. Review of undated policy titled, Plan of Care Overview: Care Conferences, revealed residents and resident representatives have the right to participate in the development and implementation of the care plan with rights to have meetings. An interdisciplinary care team participates in planning and implementation of care may include clinical team (licensed and non-licensed), therapy team, social services, activities, dietary team, medical providers, business team, administration team, family, and resident. Attendees will sign and date care plan meeting documents. 365514 Page 10 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews and policy reviews, the facility failed to provide timely assistance with discharge planning for a resident requesting to discharge from the facility. This affected one (#48) of one resident reviewed for discharge planning. The facility census was 100. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 01/28/19. Diagnoses included non-traumatic cerebral hemorrhage, hemiplegia and hemiparesis, diabetes, epilepsy and cerebral edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. Review of progress note dated 10/26/22 revealed the (previous) Administrator spoke with resident about discharge planning and sent a referral to a requested facility which was declined due to the requested facility doing renovations. Progress notes dated 03/30/23 revealed MDS Nurse #200 spoke with resident about transferring to a different nursing facility. Resident #48 reported he wanted a referral sent and MDS Nurse #200 sent the referral at 12:12 P.M. No progress notes would be provided related to resident request to the DON for facility transfer earlier in March 2023. Interview on 03/28/23 at 12:05 P.M., with Resident #48 revealed he had requested several months ago about discharge to another local facility and was unsure if a referral was sent out for review. Resident #48 revealed he spoke with the Director of Nursing (DON) recently about the referral and requested a transfer. Resident #48 denied hearing any update on his most recent request. Resident #48 reported this requested occurred about three week prior. Interview on 03/30/23 at 9:35 A.M., with MDS Nurse #186 revealed she was aware of a request when the previous Administrator was in place to transfer to another local facility. Resident #48 spoke with the previous Administrator at the time about a referral and a referral was made by the previous Administrator (due to the social worker position being vacant). The previous Administrator informed Resident #48 the requested facility was unable to accommodate his needs due to them undergoing a renovation and not taking new admissions. A progress note was placed and reviewed during the interview and confirmed to have occurred October 2022. MDS Nurse #186 revealed she was informed by the DON about a week ago about resident requesting again for a referral to be sent to another local facility. MDS Nurse #186 revealed she had taken over this task due to having no social worker in the facility and confirmed no referral or follow up had been done. MDS Nurse #186 revealed she had been busy and was helping to train the new social worker in her role. Interview on 03/30/23 at 10:06 A.M., with DON revealed she was informed by the resident of the request to transfer and she asked admissions staff about this request and was told no, the resident had already been referred and denied back in October 2022. DON revealed she did not recall speaking with MDS Nurse #186 about Resident #48's request. Interview on 03/30/23 at 10:15 A.M., with admission Staff #156 revealed she had no knowledge of Resident #48's request for transfer and revealed she had no part in the discharge planning process and handles admissions only. 365514 Page 11 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy titled Social Services dated 07/16/20, revealed social service staff were responsible for making referrals to community service agencies, and care conferences. Review of the policy titled Discharge Planning dated 07/17/20, revealed the facility had a discharge planning process in place which addresses each resident's discharge goals including referrals to local agencies. Facility should ensure the discharge needs of each resident were identified and the clinical team should work to address resident goals. 365514 Page 12 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview and policy review, the facility failed to ensure bathing was provided for dependent residents. This affected three (#64, #27, #48) of three residents reviewed for bathing. The census was 100. Residents Affected - Few Findings included: 1. Medical record review for Resident #64 revealed an admission date of 09/26/19. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, obesity, and diabetes. Review of the care plan dated 09/20/22 revealed Resident #64 has an activities of daily living (ADLs) deficit related to impaired mobility and morbid obesity. Her preference for bathing was a bed bath and Mondays and Thursdays. Review of bathing from 12/23/22 through 03/28/23 revealed out of 28 opportunities Resident #64 received 19 bed baths. There were no refusals. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 was cognitively intact. Her functional status was extensive assistance for bed mobility, toilet use with two-person physical assistance. Activity did not occur for transfers. She was physical help in part for bathing activity with one-person physical assistance. Interview on 03/27/23 at 1:11 P.M., with Resident #64 revealed she had not been receiving her bed baths on a regular basis. Interview on 03/29/23 at 3:13 P.M., with Director of Nursing (DON) confirmed Resident #64 only received 19 bed baths. 2. Medical record review for Resident #27 revealed an admission date of 02/24/23. Medical diagnoses included acute respiratory failure with hypoxia, hypertension, and diabetes. Review of the care plan dated 02/24/23 revealed Resident #27 has a ADL deficit and required assistance with ADL's related to impaired mobility, weakness, needed assistance with personal care and difficulty walking. She required one assistance with bathing. Review of bathing for Resident #27 from 02/24/23 through 03/26/23 revealed out of nine opportunities she had two showers. Review of admission MDS assessment dated [DATE] revealed Resident #27 was cognitively intact. Functional status was independent for bed mobility, transfers, eating and toilet use. She was supervision with set up help only for bathing performance. Interview on 03/29/23 at 8:14 A.M., with Resident #27 revealed she had to beg to get a bath. She stated she has not refused and only had one shower since she has been in the facility. Interview on 03/29/23 at 3:15 P.M., with the DON confirmed the resident had two showers and stated 365514 Page 13 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0677 she would look for more shower sheets. Level of Harm - Minimal harm or potential for actual harm There was no further shower sheet provided at the close of the survey for Resident #27. Residents Affected - Few 3. Review of the medical record for Resident #48 revealed an admission date of 01/28/19. Diagnoses included non-traumatic cerebral hemorrhage, hemiplegia and hemiparesis, diabetes, epilepsy and cerebral edema. Review of the MDS assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assist of two staff for bed mobility and transfers and required total dependance for bathing. Review of the care plan dated 10/2022 revealed Resident #48 had a self-care deficit with interventions including resident required two person assist with Hoyer for transfers to the shower gurney for showers. Resident #48 also refuses showers at times. Review of progress note dated 03/09/23 revealed the nurse asked why documentation stated shower did not occur resident stated his shower days were Monday and Saturday. Progress notes dated 03/09/23 revealed unit manager spoke with resident about his shower preference and reported he was happy with Monday and Thursday during night shift. Review of shower documentation and shower sheets revealed resident missed one shower the week of 12/25/22, 01/01/23, 02/12/23, 03/05/23, and 03/19/23. Resident #48 has also not been offered a shower for six to eight days at a time when also taking resident refusals into account. Observation and interview on 03/28/23 at 12:05 P.M. with Resident #48 revealed Resident #48 appeared unkempt with an untrimmed and shaggy beard and dirty fingernails. Resident #48 reported staff do not trim his facial hair during bed baths and feels that he misses showers on a regular basis. Resident #48 reported he prefers to shower, but the shower bed broke about 6 months ago and since then, he has been getting bed baths. Resident #48 revealed concerns that he has missed several of his bed baths. Resident #48 reported his shower days were either Monday and Thursday or Tuesday and Friday but could not recall which days specifically he should be getting baths. Interview on 03/30/23 at 9:32 A.M., with State Tested Nursing Aide (STNA) #121 revealed being unsure of when Resident #48 had scheduled showers. She revealed the shower scheduled was posted in the shower book and in the application on the electronic tablet software. Record review on 03/30/23 at 9:35 A.M., of the shower book revealed no master schedule was posted. Interview on 03/30/23 at 10:20 A.M., with STNA #203 revealed the electronic record tablet was how STNA's know who needs showers during their shifts. STNA #203 revealed she does not have access to the tablet and was unable to show knowledge and how it is used during the interview. STNA #203 revealed the tablet should show the shower schedule, but was unable to speak to what residents needed showers during day shift on 03/30/23. Interview on 03/30/23 at 10:25 A.M., with STNA #102 revealed the electronic tablet shows which residents have scheduled showers during their assigned shift, but it did not show all residents shower schedule. STNA #102 revealed she was unaware of a shower bed that was broken. 365514 Page 14 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/30/23 at 11:55 A.M., with DON confirmed resident choice/preference was not documented for showers and resident was not provided/offered all of his showers. The DON revealed the facility shower bench was broken for several weeks and was being reordered to replace. The DON verified residents should be at least offered showers twice weekly. Interview on 03/30/23 12:43 P.M., with the Administrator, revealed the shower bed had been broken since at least the middle of January 2022. He revealed parts were ordered to fix it but it was determined to be not fixable. The Administrator revealed residents should be able to use the shower chair and revealed staff should have informed him of this issue. The Administrator was unable to provide evidence of residents being informed or offered the shower chair as an alternative method. Review of policy titled Routine Resident Care undated, revealed routine resident care was necessary for quality of life promoting dignity and independence as possible. The facility should promote resident centered care by attending to the physical, emotional social and spiritual needs of the residents. This includes assisting with personal care including bathing. 365514 Page 15 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, activity calendar review and policy review, the facility failed to ensure a variety of activities were offered to meet residents' needs and interests. This affected two (#41 and #48) of two residents reviewed for activities and had potential to affect all facility residents. The facility census was 100. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 12/28/17. Diagnoses included chronic obstructive pulmonary disease, aortic aneurysm, poly neuropathy, dysphagia, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact with a BIMS of 15 and was independent with mobility. Review of the activity assessment dated [DATE] was completed by the activity manager and revealed Resident #41's preferred activity setting included activities in his own room and included more art themed activities and a private area for visitation for residents in semiprivate rooms. Interview and observation on 03/27/23 at 10:17 A.M., with Resident #41 revealed he would like outdoor activities and additional activities besides coloring. Resident #41 reported that he liked to color and he decorated the board in the main hallway, but he would like additional options such as cookouts, outings and games outdoors. Observation on 03/28/23 at 9:00 A.M. to 03/30/23 at 5:00 P.M., revealed the resident was not observed being offered or attending any activities besides coloring in his room. 2. Review of the medical record for Resident #48 revealed an admission date of 01/28/19. Diagnoses included non-traumatic cerebral hemorrhage, hemiplegia and hemiparesis, diabetes, epilepsy and cerebral edema. Review of the care plan dated 10/2022 revealed Resident had a self-care deficit with interventions including resident required two-person assist with Hoyer for transfers. Review of the care plan dated 10/2022 revealed Resident had little to no activity involvement due to disinterest. The care plan revealed resident enjoyed outdoor activities when the weather was nice with interventions to continue to remind and invite resident to activities, especially food related activities and to remind resident they are not required to stay for the entire activity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. Review of the activity assessment dated [DATE] was completed by the unit manager and revealed Resident #48's preferred activity setting included in his own room, inside facility and off unit and included more activities, more games, and cookouts in the summer. Observation and interview on 03/28/23 at 12:05 P.M., with Resident #48 revealed the facility does not offer a large variety of activities and revealed he would enjoy hallway or in room activities as 365514 Page 16 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many he does not spend much time out of bed. Resident #48 reported he had cat pictures that he would like to cut out and hang up and would like the activity staff to assist in this activity. Resident #48 denied he had been offered or provided any in room activities for a while. Multiple observations from 03/28/23 at 1:00 P.M. to 03/30/23 at 5:00 P.M., revealed Resident #48 did not participate in any activities and spent time sitting in his room reading the newspaper and watching television. Resident #48 was not participating in in-room activities during any observations. Interview on 03/29/23 at 3:45 P.M., with Activity Director (AD) #138 revealed she started working at the facility about a month ago and revealed the position had been empty prior to her starting. AD #138 revealed she had no previous records for the past year regarding activity attendance and revealed she was trying to start one on one visits but due to short staffing in the activity department she has only been able to get to two one-on-one visits on 03/28/23. AD #138 revealed facility did not have an activity calendar in February 2023, and the one provided was based off general things offered from staff memory. Interview on 03/29/23 at 4:13 P.M., with Administrator revealed the activity director left around 10/2022 and the new activity director started around the end of February. The Administrator revealed the Activity Director #138 did not have the credentials to be hired and the facility would assist her in going through training. Interview on 03/31/23 4:45 P.M., with Regional Director of Clinical Operations (RDCO) #125 revealed the previous Activity Director #128's last day was 11/16/22. The new Activity Director #138 was hired 02/01/23. RDCO #125 revealed during the interim time frame, the facility had no Activity Director. Review of the Activity calendar dated February 2023 revealed 26 of 28 days had coloring scheduled at 10:00 A.M. and 28 of 28 days a movie was scheduled at 5:00 P.M. The afternoon activity ranged from 1:00 P.M., 2:00 P.M. or 3:00 P.M. and included BINGO nine of 28 days; church six of 28 days; nails four of 28 days; and eight days consisted of games and crafts being scheduled. Review of the Activity calendar dated March 2023 revealed 29 of 31 days had coloring scheduled at 10:00 A.M. and 31 of 31 days a movie was scheduled at 5:00 P.M. The afternoon activity ranged from 1:00 P.M., 2:00 P.M. or 3:00 P.M. and included BINGO nine of 31 days; church seven of 31 days; nails four of 31 days and eight days consisted of games and crafts being scheduled. Review of the undated policy titled Activities Program, revealed the facility should provide centered care to meet the needs of the residents. The activity program should be scheduled daily with resident input in the planning and preparation. The activities should consist of social activities, indoor and outdoor activities, activities away from the facility, religious programs, creative activities, intellectual or educations activities, exercise activities, individualized activities, in room activities and community activities. 365514 Page 17 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0689 Level of Harm - Minimal harm or potential for actual harm 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** 2. Interview on 03/28/23 at 9:10 A.M., with Resident #31 revealed at times the bathroom sink water was too hot. Residents Affected - Some Observation on 03/28/23 from 9:29 A.M. to 9:42 A.M., revealed Resident #31's bathroom sink had a temperature of 139 degrees Fahrenheit (F) and Resident #41's bathroom sink had a temperature of 138 degrees F. Interview on 03/28/23 at 9:42 A.M., with Resident #41 revealed the bathroom sink water temperature was hot to touch. Observation on 03/28/23 from 9:50 A.M. to 10:10 A.M., with Administrator revealed water temperature as follows: Resident #31's room water temperature was 137.8 degrees F; Resident #28 and #87's room water temperature was 135.3 degrees F; Resident #23 and #41's room water temperature was 137.8 degrees F; Resident #53 and #58's room water temperature was 132.9 degrees F; Resident #2 and #10's room water temperature was 138.6 degrees F; Resident #29 and #63's room water temperature was 133.8 degrees F; Resident #66's room water temperature was 136.5 degrees F; Resident #77 and #84's room water temperature was 133.1 degrees F; Resident #48 and #60's room water temperature was 131.1 degrees F; Resident #34's room water temperature was 131.5 degrees F; Resident #36's room water temperature was 131.4 degrees F; Resident #4 and #79's room water temperature was 134.2 degrees F; Resident #12 and #59's room water temperature was 137.8 degrees F; and the 100-hall shower room water temperature was 139.4 degrees F. Interview on 03/28/23 at 10:01 A.M., with the Administrator revealed the Administrator asked, water temperatures should be under 120 degrees F, right? Interview on 03/28/23 at 10:08 A.M., with State Tested Nursing Aide (STNA) #167 revealed the water on the 100-hall had been very hot for a while and was curious to what the temperature read. A comment of look at all the steam was made. STNA #167 stated we just adjust to make sure it is safe. Interview on 03/28/23 at 10:12 A.M., from Resident #29 stated he likes to make his coffee in the sink. Interview on 03/28/23 at 10:30 A.M., with Regional Director of Clinical Operations (RDCO) #125 revealed the facility had contacted a plumber to come inspect the water heater and look at the water temperatures. RDCO #125 revealed the 100-hall had its own water heater and it does not affect any other units. Review of the facility corrective action plan dated 03/28/23 included adjusting the mixing valve to correct the water temperatures, contact a plumber, complete skin assessments on all residents affected was completed and audits were started to complete water temperatures daily for four weeks. Review of the plumbing service order dated 03/28/23 revealed a rebuild kit was ordered for the power mixing valve for the 100-hall unit. The thermostat was reset to maintain accurate temperatures until the ordered part can be replaced. Review of temperature logs dated 03/29/23 revealed all rooms in the 100 hall had temperatures 365514 Page 18 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0689 retaken and were within the 110 to 113 degree range. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Water Management program, dated 01/26/18 revealed the water temperatures for resident areas should be maintained between 105 and 120 degrees F. Residents Affected - Some Based on observations, medical record review, policy reviews, corrective action plan review, plumber work order review, resident and staff interviews, the facility failed to ensure fall interventions remained in place for a resident at risk for falls. This affected one (#54) of three residents for falls. The facility failed to ensure hot water temperatures remained in a safe range to prevent potential burns. This potentially could affect 22 (#2, #4, #10, #12, #23, #28, #29, #31, #34, #36, #41, #48, #53, #58, #59, #60, #63, #66, #77, #79, #84, and #87) residents who reside on the 100 hall. The facility census was 100. Findings include: 1. Medical record review for Resident #54 revealed admission date 12/13/22, with diagnoses including: Diabetes Mellitus 2 (DM2), chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 required extensive assistance of two or more people for bed mobility, transfers, and toilet use. The resident had occasional urinary and bowel incontinence. Review of the plan of care dated 12/22/22 revealed Resident #54 was at risk for falls with interventions including: assessing for falls on admission/readmission, quarterly, and as needed. Bed in lowest position. Complete bowel and bladder tracking program to determine toileting patterns. Ensure personal items are within reach. Ensure residents wear appropriate non-skid footwear. Ensure residents' rooms are free of accident hazards. Ensure that the bed locks are engaged. Observe medication for side effects that may increase risk for falls. Place the call bell within reach, remind resident to call for assistance. Provide adequate lighting at night. Provide assistive devices as needed. Care plan updated 03/23/23 to include Call Don't Fall signage in room to remind Resident #54 not to get up alone. Care plan updated 03/26/23 to include ensure bathroom floor is clear of clutter and obstacles. Care Plan updated 03/29/23 to include Resident #54 is not to be left alone when in bathroom. Review of nurses note dated 03/23/23 at 1:24 A.M. and 03/26/23 at 3:11 A.M., revealed the resident had unwitnessed falls with minor injuries. Observation and interview on 03/29/23 at 10:35 A.M., with Licensed Practical Nurse (LPN) #153 verified there was no signage in Resident #54 room or bathroom. Interview and observation on 03/29/23 at 10:45 A.M., with LPN #179 stated she placed signs in the room, she pointed to the wall beside the bed, she then opened the bathroom door and stated she put a sign in front of the toilet. She verified the signs were not there and wondered why they would have been removed. There were no signs noted on the floor, in the trash cans, or on furnishings. Interview on 03/29/23 at 10:49 A.M., Resident #54 stated she did remember they talked about putting up signs and talked to her about using the call light. She stated she did not remember if the signs were hung on her walls. 365514 Page 19 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 03/29/23 at 1:40 P.M., revealed an 8 x 10 inch orange Call Don't Fall reminder sign posted on the wall beside Resident #54 bed and an orange sign posted on the bathroom wall in front of the toilet. Observation on 03/30/23 at 7:45 A.M., Resident #54 resting in bed, no sign on the wall beside the bed. The signage was observed in the bathroom. Residents Affected - Some Observation on 03/30/23 at 8:15 A.M., with LPN #179 verified the Call Don't Fall sign was not on the bedroom wall. Resident #54 stated the sign would not stay on the wall. LPN #179 was unable to locate the sign in Resident #54 room. Resident #54 stated she did not know what happened to the sign. Review of the policy titled Fall Prevention and Management, revised date 06/01/22, revealed if a resident is identified to be at risk for falls, a care plan should be initiated that includes a plan to potentially diminish the risk for falls. The care plan can include interventions that address environmental factors, activities of daily living (ADL) factors, risk factors that result from dementia and other mental diagnosis, medical diagnosis that put the resident at higher risk. The care plan should be reviewed and updated as needed with each change of condition. Attempt to put an intervention in place that could prevent further falls. Attempt to identify why the resident fell and put an immediate intervention in place. 365514 Page 20 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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 observation, medical record review, staff and resident interview, the facility failed to ensure a resident was provided with incontinence supplies to prevent the potential for infections and skin impairments. This affected one (#48) of two residents reviewed for bowel and bladder incontinence during the annual survey. The census was 100. Findings included: Review of Resident #48's medical record revealed an admission date of 01/28/19, with diagnoses including nontraumatic intracerebral hemorrhage, deep vein thrombosis, diabetes and obesity. Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively intact. Resident #48 functional status was extensive assistance with two-person assistance with bed mobility and toilet use. Resident #48 was frequently incontinent of bowel and bladder. Review of the care plan dated 01/05/23 revealed Resident #48 was at risk for bowel and bladder incontinence related to impaired mobility. Interview with Resident #48 on 03/28/23 at 11:45 A.M., reported he has urgency and will go a lot when he urinates. Resident #48 revealed staff put towels into his depends due to leakage and not wanting to change the linens. Resident #48 stated he thought this was standard of care, but it causes redness and itchiness and reported he bleeds under the genital area. Observation on 03/28/23 at 3:14 P.M., revealed Licensed Practical Nurse (LPN) #169 helped Resident #48 with the urinal. A white rolled up towel was observed in Resident #48's brief. Resident #48 was without excoriation in the groin area. LPN #169 stated there was towel in the brief. 365514 Page 21 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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. Based on observation, review of policy, and staff interviews, the facility failed to ensure medications were stored with open dates and not kept past expiration dates. This affected 13 (#10, #15, #21, #87, #54, #86, #89, #96, #19, #95, #37, #64, and #27) of 13 residents' insulins observed in medication storage. The facility identified 23 Residents who currently receive insulin. The facility census was 100. Findings include: Observation on 03/30/23 at 2:41 P.M., of the 300 hall medication cart with Licensed Practical Nurse (LPN) #128 verified the Lantus insulin vial for Resident #10 had no open date or correlating expiration date. Observation on 03/30/23 at 2:55 P.M., of the 200 hall medication care with LPN #169 verified the insulin Aspart vial for Resident #15 opened 02/25/23 was expired and should not be in the cart. Observation on 03/30/23 at 3:02 P.M., of the 400 hall medication cart with LPN #123 verified the Lantus Pen for Resident #21, the Humalog vial for Resident #87, the Humalog Pen for Resident #87, and the Insulin Glargine Pen for Resident #54 had no open date or correlating expiration date noted on the medication containers. Observation on 03/30/23 at 3:09 P.M., of the medication cart for the 500 hall LPN #218 verified the Humalog vial for Resident #86, the Lispro vial for Resident #89, the Humulin N vial for Resident #96, the Lispro vial for Resident #19, the Lispro vial for Resident #95, the Insulin Glargine vial for Resident #37, the Lispro vial for Resident #37, Lantus pen for Resident #64, the Lispro pen for Resident #27, and the Aspart pen for Resident #64 did not have open dates or correlating expiration dates noted on the medication containers. When asked how she would know when the insulin medications were opened if they became separated from the pharmacy bags, the LPN #218 stated that was a good point. Interview on 03/30/23 at 5:40 P.M., Regional Director of Clinical Operations (RDCO) #125 stated there had been no adverse events related to the concern. Review of facility policy titled Storage of Medications, revised date 08/2020, revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Certain medications or package types, such as intravenous solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and record the date opened the new date of expiration. The expiration date of the vial or container will be 30 days from opening unless the manufacturer recommends another date or regulations/guidelines require different dating. The nurse will check the expiration date of each medication before administering it. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, 365514 Page 22 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0761 regardless of amount remaining. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365514 Page 23 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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. Based on observations, staff interview, and policy review, the facility failed to safely store food in the walk in freezer and dry storage areas of the kitchen. This affected all residents except Resident #16 and #76 who do not eat food from the kitchen. The facility census was 100. Finding include Observation on 03/27/23 at 9:51 A.M., revealed in the walk in freezer: chicken tenders were left open to air and undated; hamburger patties were left open to air and undated; fish patties were left open to air and updated; cinnamon rolls were left open to air and updated and three boxes of cookie dough were left open to air and undated. Observation on 03/27/23 at 9:57 A.M., revealed in the dry storage: two - one gallon bottles of red cooking wine was stamped best if used by 06/21/22. Interview on 03/27/23 at 10:03 A.M., with Kitchen Manager #181 confirmed above findings. Observation on 03/27/23 at 10:05 A.M., revealed a sign on walk-in freezer stating all items must have opening date. Review of the policy titled, Food Storage Dry Goods dated September 2017 revealed dry storage goods should be appropriately stored in accordance with FDA Food Code. The policy also revealed food in dry storage should be arranged for easy identification with the date marked as appropriate. Review of the policy titled, Food Storage Cold Food dated April 2018 revealed cold storage goods should be appropriately stored in accordance with FDA Food Code. The policy also revealed all food should be kept wrapped or in covered containers, labeled and dated. 365514 Page 24 of 25 365514 03/30/2023 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and policy review, the facility failed to ensure a complete an accurate medical record was maintained for a resident. This affected one (#48) of 33 total resident records reviewed. The facility census was 100. Finding include Review of the medical record for Resident #48 revealed an admission date of 01/28/19. Diagnoses included non-traumatic cerebral hemorrhage, hemiplegia and hemiparesis, diabetes, epilepsy and cerebral edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers and required total dependence for bathing. Review of hospital records dated 07/08/17 revealed resident had a transverse fracture of shaft of humerus with nonunion. The document also stated a resident had a bone matrix putty implanted into the right arm. Review of the facility medical record found no evidence or documentation mentioning a right upper arm deformity/bulge. Interview and observation dated 03/28/23 at 12:05 P.M., with Resident #48 revealed a large bulge in the right upper arm under his gown. The bulge was about the size of a baseball and appeared to moved when resident moved his arm. Resident #48 reported he had initially broken his arm and an implant became dislodged. Resident #48 reported some discomfort from the bulge. Interview on 03/30/23 at 9:35 A.M., with MDS Nurse #200 and MDS Nurse #186 revealed they were aware of Resident #48's bulge/right upper arm deformity but were not sure what it was from. The nurses revealed Resident #48 was admitted with this deformity and reported it should be documented in the admission assessment and facility. Interview on 03/30/23 at 10:06 A.M., with the Director of Nursing (DON) revealed she was not aware of this deformity and revealed the facility could not find any mention of it in the medical record. DON revealed the facility ordered an x-ray for the right upper extremity as a follow up. Review of undated policy titled Clinical Documentation Standards, revealed the facility would maintain a full and complete medical record through electronic medical record. A compete record contained an accurate and functional representation of actual experience of the resident and must contain enough information to show the status of the individual resident is known, and the plan of care has been identified to meet the care needs identified in the medical record. 365514 Page 25 of 25