Health inspection·January 16, 2025

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed notify the state mental health authority with a significant change Pre-admission Screening And Resident Review (PASARR) for a resident with a change in their mental health condition. This affected two (#19 and #46) of three residents reviewed for significant change PASARR. The facility census was 46. Findings include: 1. Review of Resident #19's medical record revealed Resident #19 admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below the knee, osteomyelitis, unspecified severe protein calorie malnutrition, enterocolitis due to clostridium difficile, insomnia, type two diabetes mellitus, opioid dependence, other stimulant dependence and cellulitis. Review of Resident #19's PASARR dated 09/13/23, revealed Resident #19 had no diagnoses of mental disorders. Resident #19 had a diagnosis of opioid dependence. Resident #19 did not have indications of serious mental illness. Review of Resident #19's psychiatric note dated 09/19/23, revealed Resident #19 had a diagnosis of adjustment disorder. Review of Resident #19's record from 09/19/23 to 01/09/25, revealed Resident #19 did not have a significant change PASARR or notification to the state mental health authority of Resident #19's new diagnosis of adjustment disorder on 09/19/23. Review of Resident 19's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Interview with Social Services Director (SSD) #500 on 01/09/25 at 2:22 P.M., revealed Resident #19 received a new diagnosis of adjustment disorder on 09/19/23 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #19's new diagnosis of adjustment disorder on 09/19/23. 2. Review of Resident #46's medical record revealed Resident #46 admitted to the facility on [DATE] with diagnoses including respiratory disorders in diseases classified elsewhere, insomnia, chronic obstructive pulmonary disease, carpal tunnel syndrome, pneumonia, other ventricular tachycardia and hypertension. Page 1 of 7 365529 365529 01/16/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #46's PASARR dated 12/13/22, revealed Resident #46 had no diagnoses of mental disorders. Resident #46 had a diagnosis of alcohol abuse with withdrawal. Resident #46 did not have indications of serious mental illness. Review of Resident #46's psychiatric note dated 06/02/23, revealed Resident #46 had a diagnosis of depression. Review of Resident #46's chart from 06/02/24 to 01/09/25, revealed Resident #46 did not have a significant change PASARR or notification to the state mental health authority of Resident #46's new diagnosis of depression on 06/02/23. Review of Resident 46's quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. Interview with SSD #500 on 01/09/25 at 2:22 P.M., revealed Resident #46 received a new diagnosis of depression on 06/02/23 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #46's new diagnosis of depression on 06/02/23. Review of the facility's PASRR policy dated 04/01/23 revealed the facility should follow regulations set forth by the Ohio Department of Medicaid (ODH) for PASARR. This deficiency represents non-compliance investigated under Complaint Number OH00161042. 365529 Page 2 of 7 365529 01/16/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, the facility failed to develop care plans to address residents' dental needs, medical diagnoses and use of a prosthetic limb. This affected two (#28 and #19) of three residents reviewed for care planning. The facility census was 46. Findings include: 1) Review of Resident #28's medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included necrotizing fasciitis, other complications of amputation stump, chronic viral hepatitis c, carpal tunnel syndrome bilateral upper limbs, type two diabetes mellitus with other specified complication, insomnia unspecified atrial fibrillation, chronic idiopathic constipation, and opioid dependence. Review of Resident #28's care plan from 10/14/24 to 01/08/25, revealed Resident #28 did not have a care plan to address his dental needs. Review of Resident 28's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and had no natural teeth or tooth fragments and was edentulous. Review of the facility's dental visit list dated 01/21/25, revealed Resident #28 was on the list to see the dentist on 01/21/25 for impressions for dentures. Interview with MDS Coordinator #503 on 01/09/25 at 2:47 P.M., verified Resident #28 was listed as edentulous with no natural teeth or teeth fragments on the 10/22/24 MDS assessment. MDS Coordinator #503 verified Resident #28 did not have a dental care plan to address his edentulous status or dental needs. 2) Review of Resident #19's medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included acquired absence of left leg below the knee, osteomyelitis, unspecified severe protein calorie malnutrition, enterocolitis due to clostridium difficile, insomnia, type two diabetes mellitus, opioid dependence, other stimulant dependence and cellulitis. Review of Resident #19's care plan from 08/20/23 to 01/08/25, revealed Resident #19 did not have an activities care plan or a care plan to address his left leg below the knee amputation or a prosthetic left limb. Review of Resident #19's progress note dated 04/25/24, revealed a representative from the prosthetic company delivered Resident #19's prosthesis with adjustments made on that date. Review of Resident 19's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and Resident #19 required supervision with eating, oral hygiene, showering, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, lying to sitting, chair transfers, toilet transfers, tub transfers, walking ten feet, sitting to lying, and sitting to standing. Observation of Resident #19 on 01/09/25 at 10:01 A.M., revealed Resident #19 was lying in bed. 365529 Page 3 of 7 365529 01/16/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #19 appeared clean. Resident #19 was observed to have a below the knee left leg amputation. Interview with Resident #19 at the same time revealed the resident was in therapy two to three days per week, and he was supposed to get his new prosthetic leg on 01/17/25. Resident #19 reported he had a prosthetic leg made in the past, but it was not safe because it did not have a locking feature. Resident #19 stated that the facility had activities every day, but he preferred to stay in his room and stay up late. Resident #19 reported he had been to bingo before at the facility. Interview with MDS Coordinator #503 on 01/09/25 at 2:47 P.M., verified Resident #19 did not have an activities care plan or a care plan to address his below the knee left leg amputation or use of prosthetic limb. Review of the facility's care planning policy dated March 2022 revealed the interdisciplinary team is responsible for the development of resident care plans. This deficiency represents non-compliance investigated under Complaint Number OH00161042. 365529 Page 4 of 7 365529 01/16/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0696 Provide appropriate care/assistance for a resident with a prosthesis. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure a resident's issues concerning a prosthetic limb were addressed in a timely manner. This affected one (#19) of two residents in the facility that had prosthesis. The facility census was 46. Residents Affected - Few Findings include: Review of Resident #19's medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included acquired absence of left leg below the knee, osteomyelitis, unspecified severe protein calorie malnutrition, enterocolitis due to clostridium difficile, insomnia, type two diabetes mellitus, opioid dependence, other stimulant dependence and cellulitis. Review of Resident #19's progress note dated 04/25/24, revealed a representative from the prosthetic company delivered Resident #19's prosthesis with adjustments made on that date. Review of Resident #19's physical therapy (PT) note dated 05/10/24, revealed Resident #19 was educated on the usage of the left prosthesis, and he was instructed to call the prosthetic company for a fitting issue with the prosthesis. Review of Resident #19's PT note dated 05/13/24, revealed Resident #19 was able to put on the left prosthesis and kept it on for more than two hours. Resident #19 reported feeling uncomfortable standing on it and PT instructed Resident #19 to consult the prosthetic company to possibly get another one. Review of Resident #19's PT note dated 05/17/24, revealed Resident #19 was educated about the application of the prosthesis. Resident #19 reported that the prosthetic company was making another one for him and he was instructed to use the shrinker at that time. Review of Resident #19's PT Discharge summary dated [DATE], revealed Resident #19 received PT services from 08/22/23 to 05/29/24 and Resident #19 was discharged from PT due to Resident #19 meeting the highest practical level of achievement. Resident #19 was unable to tolerate wearing the prosthesis due to reported pain and Resident #19 continued to require a manual wheelchair due to the inability to tolerate using the prosthesis. Review of Resident #19's occupational therapy (OT) Discharge summary dated [DATE], revealed Resident #19 received OT services from 05/14/24 to 07/11/24 and Resident #19 was discharged from OT due to Resident #19 being non complaint with his plan of treatment. The OT discharge summary stated Resident #19 refused to take the necessary steps to wear his current prosthetic or to prepare to be fitted for a new one. Resident #19 was non complaint with recommendations therefore his goals could not be addressed. Review of Resident 19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #19's PT evaluation and plan of treatment dated 10/28/24, revealed Resident #19 was to receive PT three times a week for thirty days. Resident 19's goal was for him to wear a prosthetic for four hours without skin breakdown or pain. Resident #19's PT baseline dated 10/28/24 365529 Page 5 of 7 365529 01/16/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0696 revealed Resident #19 had not been fitted for a new prosthetic at that time. Level of Harm - Minimal harm or potential for actual harm Review of the facility's prosthetic company clinical summary dated 12/18/24, revealed Resident #19 was seen by the prosthetic clinic. Resident #19 was seen for transtibial prosthesis of the left side for an acquired absence of the left leg below the knee. Residents Affected - Few Observation of Resident #19 on 01/09/25 at 10:01 A.M., revealed Resident #19 was lying in bed. Resident #19 appeared clean. Resident #19 was observed to have a below the knee left leg amputation. Interview with Resident #19 at the same time, revealed Resident #19 had gained weight at the facility. Resident #19 was not sure how much weight he gained but reported his weight gain was due to him being on Remeron. Resident #19 reported he was currently in therapy two to three days per week, and he was supposed to get his new prosthetic leg on 01/17/25. Resident #19 reported he had a prosthetic leg made in the past, but it was not safe because it did not have a locking feature. Resident #19 stated he was discharged from therapy in the past because they did not have enough therapy staff, but the issue was resolved, and he was back in therapy. Resident #19 stated that he received an insurance denial for his stay at the facility and the facility appealed the decision but did not include all the documents. Telephone interview with Director of Rehabilitation (DOR) #504 on 01/09/25 at 10:15 A.M., revealed DOR #504 started to work at the facility on 09/10/24 and Resident #19 had a left lower leg prosthesis that was ill fitting. DOR #504 stated that the former DOR left the facility in June 2024 and the facility had as needed (PRN) therapy staff coming into the facility, but they were not following up on Resident #19's prosthesis since he was discharged from therapy services. DOR #504 stated she started working on getting Resident #19 a new prosthesis after she started working at the facility on 09/10/24 and she found that Resident #19's insurance was never billed for the original prosthesis. DOR #504 reported the facility returned the prosthesis to the original company and Resident #19 went to another company to make a new prosthesis which was expected to be given to Resident #19 on 01/17/25. DOR #504 reported that Resident #19 had a lump on the end of his limb and the old prosthesis did not account for the lump and it did not have a pin in it. DOR #504 stated that the prosthesis also had straps that were digging into Resident #19's skin. DOR #504 verified Resident #19's original prosthesis that did not fit correctly was not followed up on from 05/30/24 to 09/10/24. Review of the care of the Prosthesis policy dated February 2018 revealed staff should report any changes, problems or complaints the resident has concerning the fitting of the prosthesis. This deficiency represents non-compliance investigated under Complaint Number OH00161042. 365529 Page 6 of 7 365529 01/16/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

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 observation and staff interview, the facility failed to ensure the facility's dishwasher was maintained in a manner to prevent foodborne illness. This affected 46 residents out of 46 residents that resided at the facility as the facility identified all residents received food from the kitchen. The facility census was 46. Findings include: Observation of the facility's kitchen on 01/08/25 at 12:17 P.M., revealed the facility's dishwasher had a wash and rinse temperature of 120 degrees Fahrenheit. Dietary Manager (DM) #502 was observed testing the chemical in the dishwasher and the dishwasher tested at zero parts per million (ppm). Interview with Dietary Manager (DM) #502 on 01/08/25 at 12:17 P.M., verified the dishwasher was 120 degrees Fahrenheit for the wash and rinse. DM #502 confirmed the dishwasher was a low temperature dishwasher and required chemical to sanitize dishes. DM #502 verified the dishwasher was running at zero ppm for chemical sanitizer This deficiency represents non-compliance investigated under Complaint Number OH00161042. 365529 Page 7 of 7