Health inspection·June 28, 2021

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a sanitary homelike environment. This affected two of eight residents (#3 and #46) sampled for ADL assistance. Facility census was 62. Findings include: 1. Resident #3 admitted on [DATE] with diagnoses that included but were not limited to unspecified dementia with behavioral disturbance, insomnia, hypertension, and major depressive disorder. 2. Resident #46 admitted on [DATE] with diagnoses that included but were not limited to unspecified dementia without behavioral disturbance, unspecified atrial fibrillation, and supraventricular tachycardia. Interview on 06/21/21 at 12:26 PM revealed State Tested Nurse Aide (STNA) #123 stated she had lad emptied the bedside commode in the morning, but did not check the bedside commode before passing lunch trays. STNA #123 verified the bedside commode was full of urine. Interview on 06/21/2021 at 1:42 P.M. STNA # 123 confirmed Resident #46's bedside commode still had urine inside, and STNA #123 confirmed she had not emptied it since morning. Observation on 06/21/2021 at 12:26 P.M. revealed Resident #46's bedside commode contained amber urine, and STNA #35 left the room without emptying the bedside commode. Observation on 06/21/2021 at 12:42 P.M. revealed STNA #139 removed Resident #46's lunch tray and left the room without emptying the bedside commode which contained urine. Page 1 of 13 365530 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

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 Based on record review, observation, interview and policy review, the facility failed to ensure toenails of dependent residents were trimmed. This affected one (Resident #28) of 17 residents sampled. The census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #28 dated 04/20/21 revealed resident was cognitively intact and required limited assistance of one staff with personal hygiene and grooming. Review of care plan for Resident #28 dated 03/08/21 revealed resident was at risk for complications with activities of daily living (ADL) self-care performance related to impaired respiratory status, impaired mobility, and mood/behavioral disturbances. Interventions included staff to provide nail care as needed. Review of the medical record for Resident #28 revealed no documentation regarding podiatry visits or refusal of foot care. Review of facility documented dated 04/07/21 signed by the attending physician revealed resident was approved to be seen by the facility podiatrist for foot evaluation-thick nails. Review of podiatrist note dated 06/24/21 timed at 11:25 A.M. revealed podiatrist was in the facility on 05/05/21 but resident refused to be seen by the podiatrist because she was in the smoking area and did not want to come down for the visit. Review of facility document dated 06/24/21 revealed Resident #28 was scheduled on as a new patient with the facility podiatrist to be seen on 06/25/21. Observation of Resident #28 on 06/21/21 at 1:30 P.M. revealed resident's toenails were long and jagged and extended past the end of her toe by approximately half an inch. During interview on 06/21/21 at 1:30 P.M. with Resident #28 confirmed her toenails were long and she had asked to have them trimmed by the podiatrist. During interview on 06/21/21 at 1:45 P.M. with Licensed Practical Nurse (LPN) #139 confirmed Resident #28's toenails were long and needed to be trimmed. LPN #139 confirmed social services handled scheduling residents to be seen by the podiatrist. Interview on 06/24/21 at 9:07 A.M. with Social Worker (SW) #750 confirmed resident had not been seen by a podiatrist since admission to the facility in December 2020. SW #750 further confirmed the resident's record did not include documentation of any refusals of podiatry. During interview on 06/24/21 at 2:00 P.M. the Director of Nursing (DON) stated the facility obtained the refusal form from the podiatrist's office on 06/24/21 documenting resident refusal of podiatry on 05/05/21. She stated the resident's record contained no documentation of the facility's efforts 365530 Page 2 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0677 Level of Harm - Minimal harm or potential for actual harm to provide or arrange for toenail care for the resident. Facility staff were not permitted to cut the resident's toenails because she was diabetic. Review of the facility policy titled Care of Fingernails and Toenails, dated February 2018, revealed the facility would ensure resident nail beds were cleaned and nails were kept trimmed to prevent infections. Residents Affected - Few 365530 Page 3 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and interview, the facility filed to failed to ensure residents received vision services. This affected one (Resident #28) of 17 residents sampled. The census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. Review of the Minimum Data Set (MDS) for Resident #28 dated 04/20/21 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living . Review of a facility document dated 04/07/21 and signed by the attending physician revealed the resident was approved to be seen by the facility eye doctor for decreased vision. Review of the medical record for Resident #28 revealed no documentation regarding eye doctor visits. Observation of Resident #28 on 06/21/21 at 1:30 P.M. revealed the resident did not wear prescription glasses. During interview at this time the resident stated her vision needed checked and she thought she might need prescription glasses. During interview on 06/24/21 at 9:07 A.M., Social Worker (SW) #750 confirmed the facility had not arranged for Resident #28 to be seen by an eye doctor. 365530 Page 4 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and policy review, the facility failed to ensure pressure relieving devices were in place to the feet for a resident with unavoidable pressure ulcers. This affected one (Resident #23) of four facility identified residents with pressure ulcers. The census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed and admission date of 02/08/18 with a diagnosis of schizophrenia. Review of Minimum Data Set (MDS) for Resident #23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Resident #23 had a physician order dated 03/01/21 for multi-podus boots to both feet as tolerated every shift. Review of the care plan for Resident #23, updated 03/09/21, revealed resident had actual impaired skin integrity as evidenced by pressure ulcers to her bilateral heels. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, pressure reducing mattress to bed, monitor/document/report to physician as needed changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage, obtain and monitor lab/diagnostic work as ordered. Review of wound physician visit note for Resident #23 dated 06/11/21 revealed the physician emphasized the importance of the facility staff following the physician's order for resident to wear multi-podus boots while in bed and in chair to offload the wound. Review of nurse progress note for Resident #23 dated 06/12/21 revealed resident was seen during wound rounds on 06/11/21 and was treated for unavoidable stage four pressure ulcers to both heels. During observation on 06/21/21 10:22 A.M., the resident was resting in bed an the multi-podus boots were not on her feet. There was a single multi-podus boot on the floor on the corner of resident's room. During interview on 06/21/21 at 10:30 A.M., State Tested Nursing Assistant (STNA) #133 confirmed Resident #23 was not wearing multi-podus boots and she didn't think Resident #23 had to wear the multi-podus boots anymore because she was on hospice. During observation on 06/21/21 at 1:40 P.M., Resident #23 was resting in bed and the multi-podus boots were not on her feet. During interview on 06/21/21 at 1:45 P.M., Licensed Practical Nurse (LPN) # 139 stated she was not sure if the resident still had an order for multi-podus boots. She stated the resident's multi-podus boots were in the nursing station. Review of the facility policy titled Prevention of Pressure Injuries, dated April 2020, revealed 365530 Page 5 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0686 Level of Harm - Minimal harm or potential for actual harm the facility would identify pressure injury risk factors and would implement specific interventions to reduce or eliminate skin breakdown. This deficiency substantiates Complaint OH00113593. Residents Affected - Few 365530 Page 6 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and policy review, the facility failed to ensure nebulizer tubing and masks were changed as ordered by the physician. This affected one (Resident #28) of 11 residents receiving respiratory treatment. The census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. Review of June 2021 physician orders for Resident #28 revealed orders for albuterol per handheld nebulizer every six hours as needed for shortness of breath and an order to change nebulizer tubing and mask once per week on Sundays. Observation of Resident #28 on 06/21/21 at 1:30 P.M. revealed resident's nebulizer tubing was dated 05/24/21. During interview on 06/21/21 at 1:35 P.M., Licensed Practical Nurse (LPN) #139 confirmed the tubing to Resident #28's nebulizer was dated 05/24/21 and it was supposed to be changed weekly on Sundays by night shift staff. Review of facility policy titled Administering Medications via a Small Volume Handheld Nebulizer, dated October 2010, revealed the nursing staff should follow any physician order pertinent to nebulizer treatments. 365530 Page 7 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, staff interview, and review of facility policy the facility filed to failed to ensure pharmacy recommendations were addressed by the attending physician in a timely manner. This affected one (Resident #28) of six residents reviewed for medications. The census was 62. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Review of the pharmacy recommendations for Resident #28 dated 01/14/21 revealed resident was at risk for venous thromboembolism (VTE) and had COVID-19. Further review of the recommendation revealed it was marked as urgent with a prompt response needed and recommended the attending physician consider temporary anticoagulant therapy due to resident's increased risk of VTE. The recommendation had not been addressed by the physician. Interview on 06/24/21 at 2:00 P.M. with the Director of Nursing (DON) confirmed the facility failed to ensure the pharmacy recommendation for the anticoagulant had been reviewed. She stated she found the recommendations in a pile in an office and stated they had not been reviewed by the physician. Review of facility policy titled Medication Regimen Reviews, dated May 2019, revealed the Consultant Pharmacist would review each resident's medication regimen at least monthly and would provide a report to the facility outlining any medication recommendations or irregularities and the facility would ensure the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. 365530 Page 8 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, interview and policy review, the facility failed to ensure orders for as needed anti-anxiety medication had a duration for the order. This affected one (Resident #23) of 19 residents with orders for anti-anxiety medication. The census was 62. Findings include: Review of the medical record for Resident #23 revealed and admission date of 02/08/18 with a diagnosis of schizophrenia. Review of Minimum Data Set (MDS) for Resident #23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Review of June 2021 monthly physician orders for Resident #23 revealed resident had an order dated 04/23/21 for as needed Ativan every two hours. Review of the June 2021 Medication Administration Record (MAR) for Resident #23 revealed the resident received as needed doses of Ativan on the following dates: 06/01/21, 06/02/21, 06/03/21, 06/04/21, 06/05/21, 06/06/21, 06/08/21, 06/09/21, 06/10/21, 06/11/21, 06/14/21, 06/17/21, 06/19/21. Interview on 06/24/21 at 3:01 P.M. with Registered Nurse (RN) #190 confirmed Resident #23's as needed Ativan order did not include a stop date. Review of facility policy titled Tapering Medications and Gradual Dose Reduction, dated April 2007, revealed the physician would review periodically whether medications were still necessary as ordered 365530 Page 9 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to ensure expired medication was timely discarded from the medication carts and the nursing station storage areas. This have the potential to affect all residents residing on the memory care unit and the third floor. The facility censes was 62. Findings include: 1. Observation on [DATE] at 6:31 A.M. of the dementia units' medication cart revealed the following opened expired stock medications: a bottle of calcium citrate plus vitamin D3 expired on 04/21, a bottle of senna-plus with an expiration date of 05/21 and a bottle of aspirin 81 milligrams (mg) with an expiration date of 04/21. 2. Observation on [DATE] at 6:45 A.M. of treatment cart in the dementia unit revealed an opened, expired, and unlabeled tube of hemorrhoidal ointment dated 02/21, opened expired tube of hydrocortisone cream 2.5 % for Resident #32, opened expired tube of desonide cream 0.5 % for Resident #27 with an expiration dated on 08/2020, an expired tube of hydrocortisone cream for Resident #11 dated 04/2021, a tube of hydrocortisone cream with an expiration date of 02/21 for Resident #22, four vials of injectable haloperidol closed with expiration date of 04/2021 for Resident #47, 90 individual packages of ABH (Ativan, Benadryl and Haldol) packaged in thirty count zip lock baggies for Resident #301 with expiration dates of [DATE], [DATE] and [DATE]. Interview on [DATE] at 7:11 A.M. with Licensed Practical Nurse (LPN) #112 verified the expired medication should have been discarded. 3. Observation on [DATE] 10:35 A.M. of medication cart on the fifth floor revealed an open and undated insulin Aspart Flexpen for Resident #8 that was half empty (75 units of 250 remaining). An open and undated Lantus Solostar glargine insulin pen for injection opened half used (180 units of 250 units remaining) for Resident #41 and a Lantus solo star insulin glargine for injection opened half (20 units remaining of 250 units) for Resident #16. Interview with LPN #137 on [DATE] at 10:50 A.M. verified the insulin pens should have labels on them indicating when they were opened. Review of the facility policy Storage of Medications, dated [DATE] revealed discontinued, outdated or deteriorated drugs or biologicals are returned to the pharmacy or destroyed. 365530 Page 10 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review, the facility failed to provide assistance with adaptive feeding equipment ordered by the physician. This affected one (Resident #314) of 17 residents sampled. The census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #314 revealed a readmission date of 06/16/21 with diagnoses including seizure disorder, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired and required supervision with eating. Review of care plan for Resident #314 dated 05/27/21 revealed had a nutritional problem or potential nutritional problem and was at risk for significant weight change. Interventions included to provide diet as ordered and assistance with eating as needed. Review of June 2021 physician orders revealed an order for resident to have sip cup with meals and supplements Review of speech therapy evaluation dated 06/02/21 revealed resident was recommended to use sip cup for fluids to promote self-feeding. Review of dietary progress notes for Resident #314 dated 06/10/21 and 06/17/21 revealed the resident was supposed to use a sip cup when consuming liquids. During observation on 06/21/21 at 11:15 A.M., a State Tested Nursing Assistant (STNA) #133 entered Resident #314's room carrying a sip cup and a carton of a liquid supplement. STNA left the sip cup on the resident's over bed table and pierced the carton of liquid supplement with the straw attached to the carton and left the room. The resident had difficulty maneuvering the straw from the supplement carton to her mouth. During interview on 06/21/21 at 11:20 A.M., Resident #314 had difficulty with word finding. When questioned about whether she thought it was easier to consume liquids using the sip cup, Resident #314 nodded yes. During interview on 06/21/21 at 11:25 A.M., STNA #133 confirmed she had taken the sip cup to the resident's room so she would have it for later. She did not pour the liquid supplement into the sip cup because she didn't think it was necessary. During interview on 06/24/21 at 11:29 A.M., Speech Therapist (ST) #700 confirmed Resident #314 should use the two-handled sip cup for all liquid consumption to promote self-feeding. Review of the facility policy titled Assistive Devices and Equipment, dated January 2020, revealed 365530 Page 11 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0810 the facility would maintain and supervise the use of assistive devices and equipment for residents including specialized eating utensils and equipment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365530 Page 12 of 13 365530 06/28/2021 Delhi Post-Acute 5999 Bender Road Cincinnati, OH 45233

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to have functioning call light available to all residents. This affected one (Resident #3) of 24 residents sampled for call lights. The facility census was 62. Residents Affected - Few Findings include: Resident #3 admitted on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, insomnia, hypertension, and major depressive disorder. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #3 required no physical staff assistance and supervision/set-up assistance with all ADL's. Record review revealed Resident #3 transferred to their current room on 05/26/2021. Observation on 06/21/21 at 1:50 P.M. revealed the room was occupied by two residents (#3 and #46), and had one call light attached to the bed of Resident #46. Resident #3 had no access to a call light. Observation on 06/22/2021 at 1:10 P.M. revealed Resident #3 had no call light. Interview on 06/21/21 at 1:52 P.M. State Tested Nurse Aide (STNA) #123 stated Resident #3's had been a private room and was recently made into a semi-private room. STNA #123 verified Resident #3 had no access to a call light on her side of the room. Interview on 06/22/2021 at 1:10 P.M. revealed Licensed Practical Nurse (LPN) #158 confirmed Resident #4 had no access to a call light. Interview on 06/24/2021 at 9:15 A.M. Administrator stated maintenance and housekeeping prepared room for transition from private to semi-private. The Administrator stated he was unaware that Resident #3 did not have call light. 365530 Page 13 of 13