Health inspection·January 15, 2025

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many 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** 2. Review of Resident #21's medical record revealed an admission date of 06/14/22 with diagnoses including chronic kidney disease, depressive disorder, peripheral vascular disease, and chronic obstructive pulmonary disease (COPD). Review of Resident #21's medical record revealed Resident #21 was transferred to the hospital on two occasions, on 04/18/24 and 04/26/24. Resident #21's electronic and hard medical chart revealed no evidence that Resident #21 was given a copy of the facility's bed hold policy before or immediately after the transfer to the hospital. Interview on 01/14/25 at 1:40 P.M. with the Owner verified the facility was not providing bed hold notices. The Owner stated the employee who was responsible for bed hold notices terminated employment and she did not assign the task to another employee. However, going forward she stated she would ensure residents and/or representatives received bed hold notices. Review of the facility's policy titled Bed-Hold Policy/Payment for Services. revised November 2017 revealed should a resident be transferred to the hospital, the resident will be notified of the bed hold policy. Based on record review, staff interview and policy review, the facility failed to ensure residents were given written copies of the facility bed hold policy upon discharge/transfer from the facility. This affected two (Residents #21 and #33) of two residents reviewed for hospitalization. The facility census was 35. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 11/18/24 with diagnoses including kidney failure, hypertension and bipolar disorder. Review of Resident #33's nursing progress noted revealed Resident #33 was discharged to an acute care hospital on [DATE] and did not return to the facility. Review of both the electronic and hard medical charts for Resident #33 revealed no evidence that Resident #33 was given a copy of the facility's bed hold policy before or immediately after his transfer to the hospital. Page 1 of 5 365533 365533 01/15/2025 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

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 record review and interview the facility failed to develop a person-centered care plan for post-traumatic stress disorder (PTSD). This affected two residents (Residents #10 and #24) out of 15 residents reviewed for care planning. The facility census was 35. Finding include: 1. Review of the medical record for Resident #10 revealed and admittance date of 10/04/24 with diagnoses including chronic obstructive pulmonary disease (COPD), venous insufficiency, post-traumatic stress disorder (PTSD), depression, dementia, type II diabetes, and chronic kidney disease. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and had moderate depression. The resident required supervision with activities of daily living. No behaviors were noted. The resident was recorded as having received antidepressant medications. Review of Resident #10's care plan dated 12/27/24 revealed the resident had potential for psychosocial well-being problems and was at risk for changes in mood related to nursing home placement. On 12/19/24, the resident was agreeable to a psychological consult at the facility and continued to see psychiatry in the community for PTSD. Interventions included psychology consult as needed and to review preferences quarterly and as needed. The plan did not identify trigger-specific interventions and ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Interview on 01/15/25 at 12:30 P.M. with Registered Nurse (RN) #850 verified she did not develop a specific care plan for PTSD for Resident #10 or Resident #24 that identified triggers or interventions to minimize or eliminate triggers. RN #850 stated that PSTD was referenced in Resident #10 nutritional, activities of daily living, and skin integrity plan. 2. Review of Resident #24's medical record revealed an admission date of 05/09/24 with diagnoses including osteoarthritis, PTSD, traumatic brain injury, type II diabetes, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required substantial to maximum assistance with activities of daily living. No behaviors were noted. The resident was recorded as having received antidepressant medications. Review of Resident #24's care plan dated 12/04/24 revealed the resident was at risk for psychosocial wellbeing decline and changes in mood related to diagnosis including depression, anxiety, parkinsonism, hydrocephalus, transient ischemic attack (TIA) a brief stroke, traumatic brain injury and PTSD. Intervention included to identify factors that influence resident psycho-social wellbeing/mood. No factors were identified. The plan did not identify trigger-specific interventions or ways to decrease the resident's exposure to triggers which could re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 365533 Page 2 of 5 365533 01/15/2025 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

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, interview, and review of the facility policy, the facility failed to ensure showers were completed for Resident #4. This affected one resident (Resident #4) of two residents reviewed for activities of daily living. The facility census was 35. Residents Affected - Few Findings include: Review of Resident #4's medical record revealed an admission date of 06/14/22 diagnoses including type II diabetes, heart disease, depression and dementia. Review of Resident #4's care plan dated 10/15/22 revealed she required assistance with bathing and dressing. Review of Resident #4's progress notes revealed a note dated 04/21/23 at 11:18 A.M. which stated the resident requested one shower per week. The resident agreed to receive a shower on Monday mornings. Review of Resident 4's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required substantial to maximal assistance with showers. Review of Resident #4's shower documentation for December 2024 revealed the resident received a shower on 12/02/24, 12/09/24, 12/16/24 and 12/30/24. There was 13 days without a shower from 12/16/25 to 12/30/25. Interview on 01/12/25 at 3:36 P.M. with Resident #4 stated she received a shower every other week. Interview with the Director of Nursing on 01/13/25 at 2:49 P.M. verified the resident received a shower on 12/16/24 and on 12/30/24, and confirmed the resident went 13 day without receiving a shower. Review of the facility policy titled Shower and bathing schedules, revised April 2023 revealed the resident bathing schedule is set-up that each resident is given at least whirlpool tub bath or shower once a week according to their preference. 365533 Page 3 of 5 365533 01/15/2025 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

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, staff interview, and policy review, the facility failed ensure food was labeled and dated in a manner to prevent food contamination and spoilage, failed to ensure expired food was disposed of timely, and failed to ensure food was served to residents in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 35. Findings include: 1. Tour of the facility's main kitchen and kitchenette on 01/12/24 between 8:00 A.M. and 8:33 A.M. with Dietary Manager (DM) #759 revealed the following that was observed and verified at the time of discovery: a. An open plastic container of sour cream with an expiration date of 01/06/25. b. Five packages of raisins with an expiration date of 11/13/24. c. An open package of liquid butter with no date. d. An open package of baking soda with no date. e. An open package of sprinkles with no date. f. An open package of marshmallows with no date. g. Four packages of orange juice thickener with a best-by date of 11/15/24. h. A peanut butter container in both the main kitchen area and kitchenette with expiration dates of 11/24/24. i. The ceiling lights directly above the kitchenette serving area had numerous dead bugs. 2. Observation of the dinner time meal service on 01/12/24 between 5:00 P.M. and 5:30 P.M. revealed the meal was being served by Dietary Aide (DA) #761. During the entire observation, DA #761 was noted to not be wearing a hair net while actively engaged in the serving of the dinner time meal. An interview on 01/12/24 at 5:33 P.M. with the Director of Nursing (DON) verified that DA #761 was not wearing a hair net as required. Review of the policy entitled Food Safety/Sanitary Conditions dated 11/01/19 revealed hair restraints must be worn to prevent hair from contacting exposed food. 365533 Page 4 of 5 365533 01/15/2025 Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070

F 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility assessment and staff interview, the facility failed to ensure its facility assessment contained all required information. This had the potential to affect all 35 residents. The facility census was 35. Findings include: Review of the facility assessment dated [DATE] revealed the assessment did not contain information on how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. Interview on 01/17/25 at 11:14 A.M. with the Administrator verified the assessment did not contain all required information on recruitment and retention of direct care staff. 365533 Page 5 of 5