Health inspection·April 25, 2019

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. Based on record review, staff and resident interview, and review of facility policy, the facility failed to treat a resident with dignity and respect when he attempted to contact the kitchen to make food choices and was hung up on three times. This affected one Resident #8 of 24 resident's reviewed for dignity during the initial pool sample of the annual survey. The facility census was 63. Findings include: During interview with Resident #8 on 04/22/19 at 11:08 A.M. and again on 04/25/19 at 9:05 A.M., the resident stated on Sunday 04/21/19, he called the kitchen around 5:30 P.M. to see why the menu was changed and why he didn't get what he ordered for dinner. The resident stated earlier that day he was told by staff that dinner consisted of roast beef and he received sausage instead, and he didn't get the vegetable soup he requested. Resident #8 stated the first time he called, a male answered the phone and hung up on him. He stated he called right back and the same male answered the phone again, Resident #8 stated he said also, and the man hung up on him again. Resident #8 stated he then waited five minutes, called back again, a female answered the phone this time, and all he said was why and she hung up on him for the third time. Resident #8 stated he had never been so disrespected in his life. Resident #8 stated he spoke with Dietary Supervisor (DS) #38 regarding the situation. During interviews with DS #38 on 04/24/19 at 1:47 P.M. and again at 5:39 P.M. DS #38 stated Resident #8 left him a message on his phone 04/21/19 stating he called the kitchen and was hung up on three times. DS #38 stated he looked into the situation and Dietary Worker (DW) #30 and #32 were both working that evening. DS #38 stated when he spoke with DW #32 he stated Resident #8 called the kitchen and was upset and yelling and cursed at him on the phone so he hung up on him. Then when Resident #8 called back, DW #32 stated he was yelling again, so he hung up on him again. Then when Resident #8 called a third time, DW #30 answered the phone and DW #32 told her to hang up on him again, and she did. Telephone interview conducted on 04/24/19 at 5:07 P.M. DW #32 stated he was working in the kitchen the night Resident #8 called. DW #32 stated when Resident #8 called, he answered the phone, and the resident was upset and yelling and cursing, so he hung up on him. Review of the facility policy titled Federal Resident Rights and Facility Responsibilities, undated, revealed the facility would abide by all resident rights, including but not limited to, treating each resident with respect and dignity in a manner that promotes quality of life and recognizes individuality. Page 1 of 10 365562 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to convey funds of residents upon discharge(discharge/death/eviction). This affected 20 (Residents #101, #102, #103. #104, #105, #106, #107, #108, #109, #110, #112, #116, #120, #121, #122, #124, #125, #126, #129, and #130) of 30 residents who discharged from the facility with remaining funds in their accounts. The facility census was 63. Residents Affected - Some Findings include: Review of medical record and facility funds record reviews revealed Resident #101 was admitted to the facility on [DATE], discharged [DATE], with a remaining balance in the funds account of $134.24 Review of the medical record and facility funds records reviews revealed Resident #102 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $85.00. Review of the medical record and facility funds records reviews revealed Resident #103 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $1,489.21. Review of the medical record and facility funds records reviews revealed Resident #104 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $51.00. Review of the medical record and facility funds records reviews revealed Resident #105 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $12.00. Review of the medical record and facility funds records reviews revealed Resident #106 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $50.00. Review of the medical record and facility funds records reviews revealed Resident #107 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $100.00. Review of the medical record and facility funds records reviews revealed Resident #108 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $25.00. Review of the medical record and facility funds records reviews revealed Resident #109 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $20.00. Review of the medical record and facility funds records reviews revealed Resident #110 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $11.00. 365562 Page 2 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0569 Level of Harm - Minimal harm or potential for actual harm Review of the medical record and facility funds records reviews revealed Resident #112 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $15.00. Review of the medical record and facility funds records reviews revealed Resident #116 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $33.00. Residents Affected - Some Review of the medical record and facility funds records reviews revealed Resident #120 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $388.01. Review of the medical record and facility funds records reviews revealed Resident #121 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $150.00. Review of the medical record and facility funds records reviews revealed Resident #122 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $22.29. Review of the medical record and facility funds records reviews revealed Resident #124 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $126.00. Review of the medical record and facility funds records reviews revealed Resident #125 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $500.04. Review of the medical record and facility funds records reviews revealed Resident #126 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $50.00. Review of the medical record and facility funds records reviews revealed Resident #129 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $2,222.24. Review of the medical record and facility funds records reviews revealed Resident #130 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $361.71. Interview conducted on [DATE] at 1:37 P.M. the Administrator verified all closed accounts had not been conveyed when residents discharged /died/evicted the facility. Administrator stated he thought the corporate office was taking care of the disbursements, and they were not. 365562 Page 3 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

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 observation, and interview, the facility failed to serve food to residents in a homelike environment. This directly affected two (Residents #13 and #53) and had the potential to affect all 14 residents present at the time of the observation. The facility census was 63. Findings include: The main dining room on Plaza 1 was observed during the lunch time meal on 04/22/19. There were 14 residents present. All 14 residents were served their food and beverage items on trays, the trays placed directly in front of the residents, and the food and beverages not removed from the tray. Resident #13 eating at a table my himself was observed removing the menu items from the tray and placing them on the table in front of where he was going to sit. In the process he dropped his bowl of tossed salad on the floor. An interview was conducted with Resident #13 on 04/22/19 at 12:32 P.M. regarding his food being served on trays. He stated that they usually place the food on the table, but not always, and he preferred to have it served on the table. Resident #53 eating lunch in the Plaza 1 dining room was interviewed during the lunch time meal on 04/22/19 at 12:29 P.M. The resident's food was served on a tray and placed in front of her. When asked if her food was typically served on a tray, or directly on the table, she reported that sometimes they serve it on the trays and sometimes they take it off; but she preferred it off the tray. An interview was conducted with Dietary Supervisor (DS) #38 on 04/24/19 at 2:10 P.M. regarding dining services, and if was facility procedure to served resident's food on a tray or placed on the table for the resident. He stated the facility's policy did not specify that resident's food and beverages were to be placed on the table for the residents, that the expectation was that all food and beverage items would be removed from the tray and placed on the table for the residents. 365562 Page 4 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to accurately assess one resident's contractures with subsequent limitations in range of motion. This involved one(Resident #33) of three residents reviewed for positioning and mobility. The facility census was 63. Residents Affected - Few Findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses including altered mental status, cerebral infarction, dysphagia, metabolic encephalopathy, aphasia, age-related physical debility, and diabetes mellitus. The facility completed a Medicare 30 day minimum data set (MDS) assessment of Resident #33's cognitive and physical functional status dated 04/09/19. The 04/09/19 assessment identified the resident as have short and long term memory problems, severely impaired cognitive sills, and requiring the physical assistance of one to two staff persons to complete all activities of daily living including eating. The resident was assessed as having no limitations in range of motion of the upper or lower extremities. Resident #33 was observed in her room on 04/23/19 at 10:11 A.M. The resident had significant contractures of her left hip, left knee, left shoulder, left elbow, and left hand. There were no splinting devices present. An interview was conducted with Therapy Manager, Doctor of Physical Therapy (DPT) #219 on 04/24/19 regarding Resident #33's contractures. She reported the resident was admitted to the facility with a history of having a stroke. DPT #219 confirmed the resident had contractures of her left upper and lower extremities. She stated the resident did not tolerate any therapy to her left lower extremity that she resisted and moaned. DPT #219 stated the resident did have contractures of her left hip, left knee, and left ankle, and that she would check with Occupation Therapy (OT) regarding the upper extremity contractures. On 04/24/19 at 3:37 P.M. a follow-up interview was conducted with DPT #219 regarding Resident #33's upper extremity contractures. She stated that she did review OT documentation and confirmed the resident did have contractures of the left shoulder, left elbow, left wrist and left hand. On 04/24/19 at 3:09 P.M. Registered Nurse (RN) #2 reviewed the assessment and affirmed the assessment identified the resident as having no limitation in range of motion. RN #2 observed the resident ad that time and stated the resident did have contractures of her left upper and left lower extremity. 365562 Page 5 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

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 observation, medical record review, and staff interview, the facility failed to ensure that residents who were unable to feed themselves reviewed the necessary services to maintain good nutrition. This affected two (Residents #18 and #33) of six residents reviewed for nutrition. The facility census was 63. Residents Affected - Few Findings include: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic pain, insomnia, depressive episodes, schizophrenia, and dysphagia. The quarterly minimum data set assessment (MDS) dated [DATE] identified the resident as having poor short and long term memory, severely impaired cognitive skills, and requiring the physical assistance of one staff person to eat. On 04/22/19 at 1:16 P.M. State Tested Nurse Aide (STNA) #102 finish passing trays on one section of rooms on Plaza 1 including Resident #18's room. On 04/22/19 at 1:28 P.M. Resident #18 was observed lying in a low bed with her meal tray covered and out of reach on an over bed table in the high position. The individual bowls of food were uncovered and the silverware unwrapped. At 1:32 P.M. STNA #102 walked into the resident's room and stated she was going to try to feed the resident as she needed help. STNA #102 affirmed the resident's food was covered, not set-up for the resident and was not within the resident's reach. STNA #102 then uncovered the food, which had been sitting at the bedside for 16 minutes, and started feeding the resident. On 04/24/19, at 2:49 P.M., an interview was conducted with Registered Dietitian (RD) #59 regarding Resident #18's self-feeding ability. She stated the residents ability to feed herself has declined over the past few weeks and now requires more assistance to maintain good nutrition. 2. Resident #33 was admitted to the facility on [DATE] with diagnoses including altered mental status, cerebral infarction, dysphagia, metabolic encephalopathy, aphasia, age-related physical debility, and diabetes mellitus. The 30 day minimum data set (MDS) assessment dated [DATE] assessment identified the resident as have short and long term memory problems, severely impaired cognitive sills, and requiring the physical assistance of one to two staff persons to complete all activities of daily living including eating. The resident received the majority of her nutrition and fluids via a gastrostomy feeding tube, and also received a mechanically altered diet. The assessment identified the resident as having weight loss since admission and not being on a prescribed weight-loss regimen. Review of Resident #33's current comprehensive plan of care identified the resident as having an self-performance deficit related to activities of daily living and was dependent on staff assistance to eat solid food. On 04/22/19, at 1:24 P.M., Resident #33 was observed in her room in a geriatric recliner with a meal tray in front of her. The resident was positioned with her body twisted to the left (her weak side), and her tray was positioned to her right side which she was able to use. However, the tray was 365562 Page 6 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0677 Level of Harm - Minimal harm or potential for actual harm not in front of her, and no one was in the room at the time the observation was made assisting the resident with eating. The resident was drinking some water from a cup with a straw but could not see where to set it down and was placing the bottom of the cup in her pureed food. After a couple minutes Licensed Practical Nurse (LPN) #83 entered the room and helped the resident set the cup down and stated they were working on trying to re-introduce solid foods to the resident. Residents Affected - Few On 04/23/19 at 5:50 P.M Resident #33 was observed lying in bed with the head of the bed elevated approximately 30 to 40 degrees. The resident's meal tray was uncovered and set up on an over bed table and had been positioned at eye level with the resident. Resident #33 was not in a position where she could see what was on her tray. The resident was yelling help me nurse. There were no staff in the room with the resident at the time. On 04/23/19 at 5:53 P.M., STNA #56 walked into the resident room. STNA #56 confirmed the resident's meal tray was at eye level. STNA #56 was asked if the resident's fed herself or was spoon fed by staff. STNA #56 stated the resident had a tube feeding and really didn't eat much. STNA #56 then asked the resident if she wanted fed and the resident stated yes and nodded in the affirmative. STNA #56 began feeding the resident pureed lasagna and the resident was opening her mouth to take the spoon. The resident then consumed a few bites of the lasagna and a few ounces of fluid with the assistance of STNA #56. 365562 Page 7 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interviews, the facility failed to have a complete water management plan to monitor for the risk, growth, and spread of Legionella. This had the potential to affect all 63 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility's Legionella plan revealed no water line tracking and/or tracking for high risk areas including but not limited to dead leg areas, ice machines, and/or tubs. The facility maintained no physical controls, temperature management including acceptable ranges for control measures, no disinfectant level controls, no visual inspection monitoring, no environmental testing for pathogens, and/or no documented results of the testing and/or corrective actions taken when control limits are not maintained. Interview conducted on 04/25/19 at 11:20 A.M. the Maintenance Supervisor (MS) #4 stated he had never received any training related to Legionella prevention in the facility. Interview conducted on 04/25/19 at 11:43 A.M. Corporate Director of Nursing (DON) #3 stated she was over the Legionella prevention for the facility. DON #3 stated there is no facility specifications that show hot spots for dead leg areas, ice machine, and/or tubs. DON #3 verified there was no noted controls for monitoring temperatures, and/or no verification of visual inspections, environmental testing, documented results, and/or corrective actions to take when limits are not maintained. 365562 Page 8 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure bed rails continued to be safe and appropriate to use when a new specialty mattress overlay was applied to the mattress. This affected one (Resident #18) of two residents reviewed for accidents. The facility census was 63. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic pain, insomnia, depressive episodes, schizophrenia, and dysphagia. The quarterly minimum data set assessment (MDS) dated [DATE] identified the resident as having poor short and long term memory, severely impaired cognitive skills, and requiring the physical assistance of one to two staff persons for bed mobility, transferring, and walking in her room and corridor. Resident #18 had two falls since the prior MDS assessment without serious injury. Review of Resident #18's current physician's orders revealed an order for bilateral assist bars while in bed for assistance with turning and repositioning. The order was dated 11/06/18. The assessment for Resident #18's side rail/transfer bars, dated 11/06/18, specified that the space between the device and the mattress was not more than one inch on either side. Review of Resident #18's nursing progress notes dated 04/17/19 at 4:03 P.M. by Licensed Practical Nurse (LPN) #87 documented new treatment orders were received to apply Aquaphor to both the resident's feet every shift for dry skin, pain abrasions to the top of her right foot with betadine, and paint the blister on the resident's right outer heel with betadine until resolved. The nurse noted there was a new intervention to float the resident's heels at all times while she was in bed, low air loss mattress with bolsters ordered via the Director of Nursing (DON) at this time. At 6:10 P.M. LPN #87 documented the resident's low air loss mattress with bolsters was delivered and installed by the mattress provided this shift. She documented the mattress appeared to be functioning without difficulty at this time. The resident was tolerating without difficulty. On 04/23/19 at 9:10 A.M. the resident's low air loss mattress overlay was observed. There appeared to be a substantial gap between the bolsters on the mattress and the grab bars that were installed on the bed frame. The resident was not in the bed at the time. On 04/23/19 at 1:35 P.M. an interview was conducted with LPN #83 regarding the resident's behaviors and if she had ever attempted to get out of bed unassisted. She reported the resident's bed is kept in the low position, that she did have a history of putting her legs over the edge of bed and trying to stand, but due to her recent bout of pneumonia she did not have the strength to get up on her own at this time. On 04/23/19 at 1:38 P.M. Maintenance Supervisor (MS) #4 measured the and verified there was a gap between the bolster and the grab bars measuring three and a half inches, and the new overlay did not fit snugly against the grab rails. However, it was evident the low air loss overlay mattress was not secured to the existing mattress and was easily shifted around the bed, and was not strapped down at the head of the bed. Subsequently, there was space between the low air loss bolsters and the 365562 Page 9 of 10 365562 04/25/2019 Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few existing grab bars that did not exist until the overlay was placed on the bed. MS #4 was asked if it was acceptable to use grab bars with the low air loss overlay, and he reported he was unsure. Manufacture's information and recommendations for the low air loss mattress overly were requested. On 04/23/19 at 3:44 P.M. Resident #18 was observed resident quietly in bed, with the bed in the low position. The low air loss mattress overlay and grab bars remained in place. The resident was not making any attempt to exit the bed. On 04/23/19 at 5:07 P.M. an interview was conducted with DON #3 regarding Resident #18's low air loss mattress overlay and the new space created between the bolsters on the overlay and the grab bars. DON #3 shared the low air loss mattress overlay was added to the resident's bed on 04/17/19, and affirmed there was no reassessment of the use of the grab rails with the bolstered low air loss mattress overlay related to resident safety. At that time DON #3 provided manufacture's information regarding the bolstered low air loss overlay. Review of the manufacturer's recommendations revealed no mention of the use of grab bars or bed rails with the low air loss overlay. On 04/23/19 at 5:30 P.M. DON #3 reported that she called the supplier for the low air loss overlay and a representative was coming out to the facility to evaluate Resident #18's bed on 04/24/19. She stated the in the interim she decide to have the grab rails removed from the bed that evening, stating she only used them when staff were assisting her in and out of the bed. On 04/24/19 at 9:54 A.M. the resident was resting in bed with the low air loss overlay mattress in place, and the grab rails had been removed from the bed frame. On 04/24/19 at 5:41 P.M. Resident #18's bed was observed while she was up for supper. The bolstered low air loss overlay now fit snuggly against the mattress and the bolsters stayed in place. 365562 Page 10 of 10