Health inspection·October 6, 2022

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 facility self reported incident review, resident interview, medical record review and staff interview. The facility failed to ensure residents were treated with dignity and respect by staff members. This affected three (Residents #50, #52 and #230) of three residents reviewed for staff treatment. The facility census was 93. Findings include: Review of facility self reported incident (SRI) #227326 created and reported on 09/27/22 indicated State Tested Nurse Aide (STNA) #104 had reported to administrative staff, STNA #214 was rude and inappropriate with Resident #230. STNA #104 indicated STNA #214 was rude and inappropriate towards Resident #230 by telling the resident she would not respond to verbal calls for assistance, and she would only respond to call light use. Further review of the SRI revealed facility staff interviewed Resident #230 and other residents in the facility which found Residents #50 and #52 also had concerns related to rude and inappropriate treatment by STNA #214. Interview with Resident #230 on 10/04/22 at 12:55 P.M. indicated a staff member was very rude and mean when talking to her a few weeks ago. States STNA #214 was mean and rude when telling her to not verbally request staff assistance to instead use her call light. Interview with Resident #50 on 10/04/22 at 1:05 P.M. indicated a staff member was very rude and mean when talking to her a few weeks ago. Resident #50 stated STNA #214 told her she did not want to have to turn her in bed because she would throw her back out. Interview with Resident #52 on 10/04/22 at 1:10 P.M. indicated a staff member was very rude and mean when talking to him a few weeks ago during care provided. Resident #52 indicated STNA #214 was hurrying him to use the bathroom when she was providing toileting assistance. Review of Resident #230's medical record revealed an admission date of 09/23/22. Further review of the medical record including the Minimum Data Set (MDS) admission assessment with a reference date of 09/30/22 indicated an independent cognition level. Review of Resident #50's medical record revealed an admission date of 02/27/22. Further review of the medical record and the MDS annual assessment with a reference date of 07/21/22 revealed an independent cognition level. Page 1 of 20 365604 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #52's medical record revealed an admission date of 04/08/21. Further review of the medical record and the MDS quarterly assessment with a reference date of 07/14/22 revealed an independent cognition level. Interview with Licensed Practical Nurse (LPN) #192 on 10/04/22 at 2:25 P.M. indicated STNA #214 had a bad attitude. LPN #192 denied any type of abuse, just poor customer service skills. Phone interview with STNA #214 was attempted on 10/05/22 at 1:15 P.M. and 2:45 P.M. but was unsuccessful. Interview with the facility Administrator on 10/04/22 at 1:40 P.M. verified STNA #214 failed to treat residents with respect and dignity and had a poor attitude when providing resident care. The Administrator indicated that STNA #214 was terminated due to poor customer service skills. This deficiency substantiates Complaint Number OH00136312. 365604 Page 2 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, electronic narcotic dispense records, policy review, schedule review and staff interview, the facility failed to ensure narcotic medications were dispensed appropriately and not misappropriated by staff members. This affected two (Residents #15 and #31) of six residents reviewed for medications. The facility census was 93. Residents Affected - Few Findings include: 1. Review of Resident #15's medical record revealed an admission date of 12/24/20 with admission diagnoses that included cerebrovascular accident with hemiplegia and hemiparesis, congestive heart failure and osteoarthritis. Review of physician's orders indicated the use of oxycodone/acetaminophen (narcotic analgesic pain medication) 5/325 milligrams (mg) every six hours as needed. Review of the electronic narcotic dispense records revealed on 09/06/22 at 5:38 P.M. and 09/24/22 at 3:54 P.M. the Director of Nursing withdrew the above narcotic medications from the Alixa electronic medication dispensing machine (electronic machine which stores narcotics and other medications for staff retrieval and disbursement to residents as indicated). Review of the Medication Administration Record (MAR) revealed no evidence the narcotic medications were administered by the Director of Nursing or any other facility staff member after removed from the Alixa machine. 2. Review of Resident #31's medical record revealed an admission date of 09/19/18 with admission diagnoses that included multiple sclerosis, diabetes mellitus and dysphagia. Review of the physician's orders revealed the use of oxycodone/acetaminophen 5/325 mg two tablets every six hours as needed. Review of the Alixa narcotic dispensing records revealed the above medication removed by the Director of Nursing on 09/09/22 at 6:31 P.M., 09/12/22 at 5:07 P.M., 09/14/22 6:06 P.M. and 09/18/22 at 4:43 P.M. Review of the MAR revealed no evidence the medication was administered after removed from the Alixa machine by the Director of Nursing. Review of the facility staffing schedule for the days identified found Licensed Practical Nurse (LPN) #103 working on the hallway with Resident #31 on all days identified for Resident #31. LPN #166 was found to be working on the hallway for Resident # 15. Phone interview with LPN #103 on 10/06/22 at 11:50 A.M. revealed she did not permit other staff members to pull any of her narcotic medications from the Alixa machine. She pulled and dispensed her own narcotic medications. Phone interview with LPN #166 was also attempted but was unsuccessful. Interview with the Director of Nursing on 10/06/22 at 10:30 A.M. verified she had removed the 365604 Page 3 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few narcotic medications from the Alixa machine and also verified there was no evidence of medications administered after the medications were removed from the Alixa machine. The Director of Nursing denied misappropriation of resident medications. Review of the facility Abuse Prohibition policy with a revision date of November 2017 indicated, The health care center's management prohibited neglect, mental or physical abuse, including mental abuse associated with the unauthorized or authorized use of photographs and recording that are used in a manner to demean or humiliate a resident including, but not limited to photographs and recordings uploaded to social media, involuntary seclusion and misappropriation of resident's property and/or funds. This deficiency substantiates Complaint Number OH00136312. 365604 Page 4 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and review of personnel files, the facility failed to ensure employees did not have a finding entered into the State of Ohio Nurse Aide Registry. This had the potential to affect all 93 residents residing in the facility. Residents Affected - Many Findings include: Review of personnel files revealed Licensed Social Worker #116 hired on 08/03/22, Business Office Manager #176 hired on 06/02/22, Licensed Practical Nurse (LPN) #183 hired on 04/03/17, LPN #186 hired on 05/20/22, Housekeeper (HSK) #137 hired on 06/10/22, HSK #169 hired on 08/26/20 and Registered Nurse #112 hired on 01/10/17 lacked evidence they were checked through the State of Ohio Nurse Aide Registry to determine if they had a finding of abuse, neglect, exploitation, mistreatment of residents or their property. Interview with Human Resource/Personnel Manager #192 on 10/06/22 at 11:30 A.M. verified there was no evidence in the personnel file provided but indicated the administrator handled that portion. The records were requested. On 10/06/22 at 3:52 P.M. the facility provided evidence they used a computer system that searched data bases throughout the United States. The form had a banner across the top with each state listed. For Ohio, Medicaid was listed. There was no evidence the staff were checked against the State of Ohio Nurse Aide Registry. Review of the abuse prohibition policy and procedure revised in November 2017 indicated screening was mandated for all employees and would not proceed with hiring any professional that had been found guilty or had an active disciplinary action against them by a state licensing agency. 365604 Page 5 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital and send a copy of the notice to the Long-Term Care Ombudsman. This affected one of two residents (#81) reviewed for hospitalization. Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including respiratory failure. Review of the progress note dated 08/02/22 at 4:08 A. M, revealed Resident #81 had a sudden change in condition and was sent to the hospital for hypoxia, sepsis and hypothermia. On 08/10/22 at 7:00 A. M. he again had a change in condition and was sent to the hospital. There was no evidence in the record the resident/representative were notified of the transfer and the reason for the move in writing nor a copy of the notice sent to the Long-Term Care Ombudsman. Interview with the Director of Nursing on 10/05/22 at 1:45 P.M. indicated the facility had changes in the business office and social services and the notices were never sent. 365604 Page 6 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

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 interview and record review, the facility failed to notify the resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment. This affected two residents reviewed for hospitalization (#35 and #81) of 93 residents in the facility. Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including respiratory failure. Review of the progress note dated 08/22/22 at 4:08 P.M. indicated Resident #81 had a sudden change in condition and was sent to the hospital where he was diagnosed with hypoxia, sepsis and hypothermia. He was sent to the hospital again on 08/10/22 at 7:00 A.M. for a change in condition for respiratory issues. There was no evidence the resident/representative were notified of bed hold days remaining. Interview with the Director of Nursing on 10/05/22 at 1:45 P.M. indicated between staffing changes with the business office and social services, bed hold notes were never sent. Interview with Social Worker #116 on 10/05/22 at 2:27 P.M. verified no bed hold notice was provided. 2. Review of Resident #35's medical record revealed diagnoses including chronic obstructive pulmonary disease and end stage renal failure. Review of the progress note dated 09/30/22 at 2:38 P.M. indicated Resident #35 wanted to go to the hospital for abdominal pain. A voicemail was left for Resident #35's emergency contact. The Resident acute change in condition assessment dated [DATE] indicated Resident #35 had abdominal pain which started on 09/24/22 and loose stools. Resident #35 was diagnosed with abdominal pain and clostridium difficile. There was no evidence a bed hold notice was provided. Interview with Social Worker #116 on 10/05/22 at 2:27 P.M. verified no bed hold notice was provided. 365604 Page 7 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

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 medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review was resubmitted after a significant change with new updated mental illness diagnosis. This affected two (Resident #31 and #64) of two residents reviewed for pre-admission screening and resident review. The facility census was 93. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 09/19/18 with admission diagnosis that included multiple sclerosis. Review of the Pre-admission Screening and Resident Review (PASRR) revealed PASRR completed on 07/16/18 which indicated no evidence of serious mental illness. Further review of the medical record revealed on 12/08/21 a new diagnosis of schizoaffective disorder was added by the physician. Interview with Licensed Social Worker (LSW) #116 on 10/05/22 at 9:50 A.M. verified a PASRR was not resubmitted for review after a new serious mental illness diagnosis was added for Resident #31. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, personal history of traumatic brain injury, type II diabetes mellitus without complications, schizophrenia, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/02 for Resident #64, revealed the resident had intact cognition. Review of the 03/18/16 Preadmission Screening Tool revealed Resident #64 was not applicable. Review of Resident #64's medical records revealed a diagnosis of schizoaffective disorder was added on 10/12/16 and a diagnosis of schizophrenia was added on 01/01/18 and no evidence was found in the medical records of a significant change PASRR form being submitted to the state mental health agency to decide if Resident #64 needed level II services. Interview on 10/05/22 at 2:29 P.M. with Social Worker #116 confirmed there was no PASRR completed. 365604 Page 8 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

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 resident interview, observation, medical record review and staff interview, the facility failed to ensure residents dependent upon staff assistance with meals were provided assistance as indicated. This affected one (Resident #31) of three residents reviewed for assistance. The facility census was 93. Residents Affected - Few Findings include: Interview with Resident #31 on 10/03/22 at 9:30 A.M. revealed staff members did not assist him with meals. Observation of Resident #31 for the lunch meals on 10/03/22, 10/04/22 and 10/05/22 revealed no evidence of staff assistance with meals. Resident #31 was independently feeding himself while having significant hand and arm tremors resulting in difficulty eating and a large amount of food debris on the chest of the resident. Review of Resident #31's medical record revealed an admission date of 09/19/18 with admission diagnosis that included multiple sclerosis. Further review of the medical record including the quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 08/16/22 indicated Resident #31 had an independent cognition level and required assistance of one staff member for eating meals. Review of Resident #31's care plan revealed a Self Care Deficit care plan related to multiple sclerosis. Interventions included one assist by a staff member with meals. Observation and interview with the Director of Nursing on 10/05/22 at 12:15 P.M. verified no evidence of staff assistance provided during the lunch meal. 365604 Page 9 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

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, interviews, record and activity calendar review, the facility failed to provide an ongoing activities program for the residents on the secured dementia unit to improve boredom, loneliness and frustration that could result in distress or agitation. This affected three of three residents (#8, #63, and #73) reviewed for activities with the potential to affect all 23 residents on the secured dementia unit in a facility of 93 residents. Residents Affected - Some Findings include: Observations on the secured dementia unit on 10/03/22 at 9:50 A.M. revealed eight residents asleep in the dining room. At 10:23 A.M. the same eight residents were in the dining room with nothing going on. Interview with Licensed Practical Nurse (LPN) #153 and State Tested Nurse Aide (STNA) #146 reported activity staff did not come onto the unit a lot. Meal service began at 11:21 A.M. and continued through 12:35 P.M. Activity Aide (AA) #167 arrived on the unit with a beach ball at 12:28 P.M. but residents were in the middle of meal service, and she left the unit. At 3:27 P.M. AA #167 was observed rolling a beach ball across the table in the dining room to one resident (#30). The dinner meal service began at 4:06 P.M. Interview with Resident #8's family on 10/03/22 at 1:10 P.M. indicated they visited two to three times per week and there were no activities going on but indicated activities met with them to find out Resident #8's interests. Observation on 10/04/22 revealed the lunch meal service began at 10:59 A.M. At 11:30 A.M. meal service continued. At 1:24 P.M. residents were seated in the same spot where they ate lunch and AA #167 had four of the residents engaged in a craft activity with music playing. Observation on 10/05/22 at 9:49 A.M. revealed AA #167 arrived on unit with an activity cart and left the unit at 10:21 A.M. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia and schizophrenia. Review of the admission comprehensive assessment dated [DATE] indicated Resident #8 was severely cognitively impaired. The daily preferences that were very important to her included choice in clothing, taking care of her things, choice in the type of bath, to have snacks between meals, choose bedtime, to have family involved in decisions about her care. Her activity preferences that were very important were books, newspapers, magazines to read, listen to music that she liked, to be around animals, keep up with the news, do things with groups of people, to do her favorite activities, go outside and get fresh air, participate in religious services or practices. She required the extensive assistance of one person for eating, the extensive assistance of two persons for toilet use and personal hygiene. Review of the plan of care related to altered activities patterns pursuits related to dementia indicated Resident #8's current level of activity would be maintained, would express satisfaction with the type of activities and the level of activity involvement when asked through the next review. Interventions included allow to make choices about preferred activities, encourage participation in activities, enjoys family visits, television and listening to country music, and encourage to attend and 365604 Page 10 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0679 participate in programs. Level of Harm - Minimal harm or potential for actual harm Review of the activity participation records since Resident #8's admission revealed for September 2022 she participated daily in current events/coffee, family visits, reading/writing/mail, sensory stimulation, social visits, talking/conversation, walking/wheeling outside. She participated in resident-to-resident interaction and watching television/radio 26 times. She watched one movie, attended two music/entertainment and two party/socials. Review of the one-to-one visits indicated on 09/03/22 she was welcomed to the facility, given a little friend, and asked questions. On 09/13/22 she enjoyed the petting zoo with her family liking the little goats and the brown cow and on 09/20/22 she came off the unit and enjoyed the country singer. Review of the four days in October 2022 activity participation record indicated she went to the beauty shop one time and daily participated in current events/coffee, games/cards/trivia, music/entertainment, resident to resident interaction, reading/writing/mail, sensory stimulation, walking wheeling outside and watching TV and radio and one exercise/sports. Resident #8 was observed at various times from 10/03/22 through 10/06/22 and had not participated in all the activities that were documented. Residents Affected - Some Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, adult failure to thrive, transient cerebral ischemic attack, cerebral infarction due to occlusion or stenosis of cerebral artery, Alzheimer's disease, bipolar disorder depressed moderate, major depressive disorder, anxiety disorder, dementia with behavioral disturbance, and psychotic disorder with delusions due to known physiological condition. Review of the annual comprehensive assessment dated [DATE] indicated Resident #63 was independent in daily decision-making ability. It was very important to have books/newspapers/magazines to read, music that he liked, pets, keeping up with the news, with groups of people, going outside and, religious practices. Review of the activity assessment dated [DATE] indicated he preferred large group, small group, family, individual, community/outings, own room, day/activities room, inside facility/off unit, outside facility activities. Present activity interests were table games, religious activities, group exercises, word games, checkers, and music programs. He was motivated and willing to try. He was most happy when he saw his family, he wished to be healthy again and the reason he was here was because he needed assistance. Review of the plan of care indicated Resident #63 was placed on the secured dementia unit as a therapeutic environment for his dementia. A plan of care initiated on 09/29/22 indicated he was at risk for altered activity pattern/pursuits related to dementia. The goal was to express satisfaction with the type of activities and level of activity involvement when asked through the next review. The interventions were to allow him to choose preferred activity pursuits, encourage to accept redirection into group activities to increase socialization, monitor impact of medical problems on activity participation and provide periodic friendly visits for increased socialization. Review of the activity participation records indicated in August 2022 Resident #63 had four one-to-one visits. Watched television/movies, spiritual services, reading/being read to, socializing/reminiscing, sensory/activities daily. He received communion once on 08/25/22. The one-to-one visit on 08/04/22 indicated his favorite color was blue, he liked pizza and loved to go outside. On 08/11/22 he said he was having a good day. He was provided ice for his water and helped to change the channel on his television. On 08/18/22 he was provided a beverage because he was thirsty and noted he said he used to do a lot of activities until he got sick so he could not enjoy them as much. It was noted activity staff would love to see him participate in more activities. The September 2022 activity participation records indicated he participated in current events/coffee, sensory stimulation, 365604 Page 11 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some talking/conversation and watching television/radio daily. He participated in arts and crafts once. He had 16 family visits. He watched movies 28 times, attended two parties, and had one pet visit. He received 21 social visits, he was wheeled outside four times. The one-to-one visit dated 09/08/22 indicated he wanted to lay back down but was told he should wait because lunch was coming soon. It was explained to him the importance of getting out of bed. On 09/15/22 he was ready for lunch and asked if the activity staff would be feeding him. He was told no but someone would feed him shortly. On 09/22/22 he was yelling and said he was okay and did not know why he was yelling. He was told if he needed something not yell because they were always there. Review of the October 2022 activity participation records for four days revealed he had one family visit, four resident to resident interactions, four reading/writing/mail, four sensory stimulation, four talking/conversation and four watching television and radio. He was observed to stay in his room from 10/03/22 to 10/05/22. The activities documented did not occur. On 10/03/22 he was either yelling help or activating his call light with high frequency. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, asthma, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, polyneuropathy, major depressive disorder recurrent severe with psychotic symptoms, idiopathic peripheral autonomic neuropathy, prostate cancer, obesity, hypertensive retinopathy, schizoaffective disorder, bipolar disorder, psychosis, chronic ischemic heart disease, edema, vitamin deficiency, insomnia, intellectual disabilities, atherosclerotic heart disease, hypertension, end stage renal disease, lymphedema, major depressive disorder severe with psychotic features and hyperlipidemia. Review of the annual comprehensive assessment dated [DATE] indicated Resident #73 was severely cognitively impaired. He displayed no behaviors. The activity preferences that were very important included listening to music, doing things with groups of people, going outside, and getting fresh air. Resident #73 had functional limitation in range of motion of the upper and lower extremities. He did not receive therapy services or restorative services during the assessment period. Review of the activity assessment dated [DATE] revealed Resident #73 enjoyed large groups, small groups, individual, own room and day/activity room activities. Present interests included paint/draw/color, table games, religious activities, group exercises, word games and music programs. His attitude toward life and activities in general were motivated. He liked to paint pictures when able, listen to jazz/Motown music, watch football on television, socialize with others, food programs, liked to listen to his CD player and liked to people watch. He was most happy when he was with people and if he could do anything he wanted it would be paint pictures. Review of the care plan initiated on 08/22/2 indicated Resident #73 was at risk for altered activity pattern/pursuits related to dementia and impaired mobility. The goal indicated he would accept/interact with others during one-to-one visits. The interventions included allowing him to make decisions about preferred activity pursuits, encourage participation in small groups to promote a sense of ease/belonging and to decrease the potential for anxiety, provide escort to/from activity programs as needed and provide periodic friendly visit for increased socialization. Review of the activity participation records for August 2022 indicated Resident #73 participated daily in television/movies, reading/being read to, socializing/reminiscing, sensory activities, and cognitive activities. The one-to-one activity provided on 08/03/22 indicated he was asked if he liked the professional football team, he nodded and smiled. He kept his eyes open. On 08/06/22 he said he was okay. The activity aide told him she missed him and he looked at the football poster on the 365604 Page 12 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wall. On 08/10/22 he was asked if he was excited about football, he shook his head and smiled really big. On 08/17/22 he was in the dining room and an old television show was on the television. Someone on the television said a funny joke and he laughed. He was asked it that was funny and he nodded his head. On 08/20/22 he was looking at his meal while being talked to. He shook his head when asked if he was hungry. On 08/24/22 he was read the daily chronicle and seemed to like it. He opened his eyes and mumbled while it was being read. Review of the September 2022 activity participation records revealed daily he participated in sensory stimulation, and social visits. He watched television/radio for 29 days. He attended current events/coffee 28 times, movies 19 times, pets six times, resident-to-resident interaction 20 times, reading/writing/mail four times. The one-to-one visit dated 09/03/22 indicated he was read the daily chronicle and looked when it was being read. On 09/07/22 read to him and he opened his eyes when he his name was said, he smiled and giggled a little. On 09/10/22 activity aide fed him his lunch, spent extra time with him and read him the daily chronicle. On 09/13/22 did a craft with him. Held up option and he nodded which colors and stickers he liked. On 09/17/22 he looked when his name was called. He was told the football team won and he looked at the poster on the wall. On 09/24/22 the activity aide fed him his lunch. He was told she enjoyed feeding and talking to him. On 09/28/22 he was asked if he wanted a show turned on for him, he nodded yes and was laughing at the show. Review of the participation records for the first four days of October 2022 indicated he participated in two current events/coffee, two music/entertainment, four resident-to-resident interactions, four sensory stimulation, four social visits, one spiritual/religious and four television/radio. He had a one-to-one visit on 10/01/22 he just opened and closed his eyes. He was not talking or moving his head when spoke to. Observations revealed Resident #73 seated in a custom wheelchair with his head cocked to the right or lying-in bed. No meaningful activities were observed to be provided to him as indicated on the participation records. On 10/05/22 at 3:21 A.M. he expired in the facility. Interview with Activity Director (AD) #182 on 10/05/22 at 9:36 A.M. indicated she had one full time and one part time activity aide. She reported AA #167 was going on to become a State Tested Nursing Aide (STNA). She was informed the activities were not provided as scheduled and the documentation did not accurately reflect the actual activities provided and were not based on their individual assessments. She was also informed the residents who did get out of their room stayed in the dining room all day. There were two other common areas that were not utilized to offer a change in scenery. Observation on 10/06/22 at 10:06 A.M. revealed AD #182 on the secured dementia unit provided a ring toss activity in the dining room. AD #182 reported AA #137 began her STNA training today. Review of the posted activity calendar indicated on 10/03/22 at 9:30 A.M. was table chatter, 10:00 A.M. story time, 12:00 P.M. country melodies, 2:00 P.M. I Love [NAME], 3:00 P.M. one to one visit, 3:30 P.M. dinner table chatter, 4:00 P.M. soft music and 6:00 P.M. evening snacks. On 10/04/22 at 9:30 A.M. table chatter, 10:00 A.M. balloon toss, 12:00 P.M. easy listening, 1:30 P.M. national taco day craft, 4:00 P.M. soft must and relax, and 6:00 P.M. evening Bingo. On 10/05/22 at 9:30 A.M. was table chatter, 10:00 A.M. pretty dazzle nails, 12:00 P.M. easy listening, 2:00 P.M. wagon train, 3:00 P.M. one to one visit, and 4:00 P.M. soft music. On 10/06/22 at 9:30 A.M. was cookies and milk, 10:00 A.M. communion, 10:30 A.M. residents' council, 12:00 P.M. easy listening, 2:00 P.M. wagon train, 4:00 P.M. soft music and relax, and 6:00 P.M. evening bowling. 365604 Page 13 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to reassess and implement interventions for Resident #8's nutritional status following an identification of poor intake resulting in a significant weight loss. This affected one resident (#8) out of three residents (#40 and #284) reviewed for nutrition. Residents Affected - Few Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes with neuropathy, hypothyroidism, dementia, reflux, major depressive disorder, hyperlipidemia, pneumonia, sepsis, esophagitis, esophageal obstruction and schizophrenia. Review of the admission comprehensive assessment dated [DATE] indicated Resident #8 was severely cognitively impaired and required the extensive assistance of one person for eating. Review of Resident #8's plan of care related to altered nutrition indicated to monitor/report swallowing issues, monitor meal intake percentages, periodically obtain weight, and provide feeding/dining assistance. Review of Resident #8's weights revealed the following: On 09/03/22 - 145 pounds (lbs), On 09/07/22 - 143 lbs, On 09/15/22 - 144 lbs, On 09/22/22 - 139.9 lbs, and On 09/29/22 - 137 lbs indicating a significant weight loss of 5.52% in 26 days. Review of the physician's orders indicated Resident #8 was placed on fortified foods on 09/24/22 and on 09/27/22 her diet was downgraded to puree consistency per speech therapy. On 09/29/22 at 11:56 A.M. Food Service Supervisor (FSS) #185 noted Resident #8 was reviewed during a risk meeting. FSS #185 noted Resident #8 was showing a weight decline since her admission and her meal intakes declined to 0-25 percent over the past week or so. FSS #185 noted Resident #8 required assistance from nursing staff for eating. FSS #185 indicated the registered dietitian requested a re-weight. Review of the medical record lacked indication Resident #8 was re-weighed. The lunch meal was observed on the secured dementia unit on 10/03/22 beginning at 11:21 A.M. when the food cart arrived on the unit. At 11:32 A.M. there were nine residents in the dining room. Each resident was provided a meal on disposable plates including Resident #8. At 12:10 P.M., Resident #8 was looking straight ahead making no attempt to feed herself. Staff attempted to feed Resident #8 but she preferred liquids and ate less than 25 percent. 365604 Page 14 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident #8's family on 10/03/22 at 1:10 P.M. indicated they visited Resident #8 two to three times per week. They visited yesterday and had concerns she was not being fed and would not feed herself. They noticed other residents were not provided assistance with eating and this was not the first time. They indicated one resident asked them to feed her. The dinner meal was observed on 10/03/22 beginning at 4:29 P.M. At 4:38 P.M. a meal was given to Resident #8. Licensed Practical Nurse #157 indicated Resident #8 usually fed herself, but she would assist her because she was making no attempt to eat. Again, Resident #8 very little. Review of meal intake records indicated on 10/03/22 for breakfast and lunch Resident #8 ate between 51-75 percent and she refused dinner. Observation on 10/04/22 at 11:30 A.M. revealed Resident #8 was provided a lunch meal and was encouraged but would not eat. Review of meal intake records indicated on 10/04/22 for breakfast and dinner Resident #8 ate between 51-75 percent and lunch was between 76-100 percent. Observation on 10/05/22 at 11:38 A.M. revealed Resident #8 was provided a lunch meal. State Tested Nurse Aide (STNA) #172 encouraged Resident #8 to eat but she would not and stared straight ahead. Resident #8 would accept fluids and was provided three cups of fluid. STNA #172 asked Resident #8 to slow down so she would not get filled up. STNA #174 asked Resident #8 if she wanted a bite of food and Resident #8 would say no so a bite was not attempted. STNA #174 said she could not force Resident #8, but other staff had been observed to put food to her mouth and she would take a bite. Review of the meal intake records indicated on 10/05/22 Resident #8 refused breakfast and ate 0-25 percent at lunch. On 10/06/22 at 7:30 A.M. Resident #8 was in bed asleep. STNAs #174 and #201 were asked how Resident #8 did for breakfast. Both reported Resident #8 did not eat breakfast because she preferred to sleep. Resident #8's weight was requested. On 10/06/22 at 9:07 A.M. STNA #201 weighed Resident #8 and reported her current weight was 131.3 lbs. This indicated further weight loss. A significant weight loss of 9.66 percent since her admission to the facility. Interview with Registered Dietitian (RD) Consultant #212 on 10/06/22 at 9:40 A.M. indicated she was aware Resident #8 had an esophageal stricture, was assessed by speech therapy, her diet downgraded and fortified foods were put into place. She was informed on 09/29/22 Food Service Supervisor #185 noted her meal intake had declined to 0-25 percent in the past week, required assistance in feeding from nursing staff and requested a re-weight. There was no evidence the reweigh was completed. RD #212 was informed her weight was requested due to the observations of feeding and intake marked did not match the observations. On 10/06/22 her weight was 131.1 lbs. indicating a 9.66% loss since her admission. RD #212 indicated she would complete a comprehensive assessment and put interventions and possibly referrals in place. 365604 Page 15 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Based on observations, interviews, review of activity calendars, review of staffing patterns and review of the facility assessment, the facility failed to have sufficient quantity of staff to provide the necessary behavioral health, psychosocial and dementia care to residents with consideration of the number, acuity, and diagnoses of the residents. This affected all 23 residents (#7, #8, #14, #26, #30, #34, #40, #41, #44, #48, #55, #59, #61, #62, #63, #68, #69, #70, #73, #74, #75, #130, and #131) on the secured dementia unit out of 93 residents. Findings include: Observations on the secured dementia unit on 10/03/22 at 9:50 A.M. revealed eight residents asleep in the dining room. The remainder of the residents were in their rooms for the entire day. The posted activities were not being delivered. There was one Licensed Practical Nurse (LPN) #153 and one State Tested Nurse Aide (STNA) #146 for 23 residents. LPN #153 and STNA #146 were observed physically running to respond to alarms sounding and call lights. Interview with LPN #153 and STNA #146 on 10/03/22 at 10:30 A.M. reported it was very difficult when there was only one STNA on the unit. Many of the residents required assistance of two staff, needed fed and, reminded not to rise unattended. They verified activity staff were not on the unit very much to keep the residents engaged. Observation on 10/03/22 at 11:21 A.M. revealed the meal cart arrived on the secured dementia unit. There were nine residents in the dining room. At 11:46 A.M. there were 11 meal trays yet to be served. Activity Aide #156 was on the unit helping pass trays and encouraging residents to eat. LPN #153 sat to feed to two residents in the dining room as she was verbally cueing other residents to eat. Resident #40 received his tray at 11:55 A.M. The tray sat on his over bed table. At 11:55 A.M. all the trays were still not passed to the residents. At 12:10 P.M. Resident #8, #34, #73, and #74, seated in the dining room, all needed extensive assistance in eating the meal. At 12:18 P.M. Resident #34 and at 12:22 P.M. Resident #26 received their trays. During this same time Resident #30's chair alarm kept sounding and the staff stopped what they were doing to check on her. At 12:24 P.M. Resident #40 had yet to be fed. At 12:27 P.M. STNA #157 arrived and began to collect food trays. LPN #153 sat to feed Resident #40. Activity Aide #167 arrived on the unit at 12:28 P.M. with a beach ball but residents were in the lunch process. She left the unit at 12:34 P.M. Resident #14's food was untouched. In general there was a lot of plate waste. STNA #157 was on the unit until 2:30 P.M. when she was told by management to work on a different unit. Interview with Resident #8's family on 10/03/22 at 1:10 P.M. indicated the family visited two to three times per week. During yesterday's visit the family had concerns she was not being fed. The family noted several other residents needed fed, were not provided the assistance and this was not the first time. Resident #8 had been found by the family to not be cleaned properly after a bowel movement and they had also found her completely soiled to the point she needed to be bathed. The family noted the residents just sat in the dining room without staff present and no activities. Observation on 10/03/22 at 3:27 P.M. revealed Activity Aide #167 rolling a beach ball to one resident (#30). None of the activities on the activity calendar were provided on 10/03/22. There were no observations of staff utilizing techniques including music, art, massage, aromatherapy or reminiscing or relocating residents to an alternate room that was available so they would have a change in scenery. 365604 Page 16 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 10/03/22 at 4:06 P.M. revealed STNAs #159 and #209 passing room trays. Only half of the residents were served. There were seven residents in the dining room and one STNA, STNA #209 feeding Resident #59 who was fretting. STNA #159 was observed in a room feeding a resident and Resident #34's daughter was assisting Resident #34 to eat. At 4:29 P.M. STNA #159 brought the cart from the dining room to the end of the short hall. At 4:35 P.M. STNA #209 prepared to feed Resident #40. At 4:38 P.M. STNA #209 determined Resident #73 was not sent a meal tray and left the unit to obtain a meal tray. LPN #157 sat to feed Resident #8. At 4:45 P.M. Residents #70, #75, and #130 had yet to receive their meal trays. At 4:47 P.M. STNA #159 returned with a meal tray and went feed Resident #73. At 5:06 P.M. STNA #157 went to feed Resident #70. At 5:04 P.M. Resident #130 finally received her meal, a little over an hour after it was brought to the unit. At 5:11 P.M. Resident #130's meal sat in front of her, and she made to attempt to eat and received no help as the STNAs began to collect meal trays. Interview with LPN #153 on 10/04/22 at 10:59 A.M. reported yesterday's meals were such a disaster she had to inform the administrator more staff were needed on the unit who understood dementia residents. Review of the STNA assignment sheet revealed nine resident's had alarming devices to prevent falls, Residents #30, #44, #48, #59, #68, #69, #70, #73, and #74. Seven residents were identified as requiring a mechanical lift and two staff for transfers, Residents #40, 61, #63, #70, #73, #74, and #75. Review of the as worked staffing for the secured dementia unit since 09/03/22 revealed there were 22 shifts with one aide and one nurse on the first and second shifts and not for full shifts. Interview with STNA/scheduler #202 on 10/04/22 at 9:00 A.M. indicated she scheduled staff by census and used agency staff to supplement. She indicated the overall goal was to have two staff per shift per wing but she could not control call offs. She verified the secured dementia unit was one of the heaviest care halls because they had residents that roamed and they would be provided two aides before the other units. Interviews with LPN #157 and STNAs #172, #201, and #211 between 10/04/22 and 10/05/22 at various times all reported the secured dementia unit was difficult because of the number of residents who needed fed, were at risk for falls or used a mechanical lift to transfer. Review of the facility assessment tool dated 09/14/22 indicated the average daily census was 88-95 residents. The staffing plan was built to ensure sufficient staff to meet the needs of the residents at any given time and fluctuated based on the census and acuity levels impact staffing needs. 365604 Page 17 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, review of pharmacy delivery records, and interview, the facility failed to ensure ordered medications were available for administration. This affected one (Resident #181) of five residents reviewed for medication use and one additional resident (Resident #185) who addressed a concern during initial review. Findings include: 1. On 10/03/22 at 11:20 A.M., Resident #185 stated she was concerned she had not received her thyroid medication for three days. Review of Resident #185's medical record revealed an admission date of 09/18/22. Diagnoses included hypothyroidism. Review of the September 2022 Medication Administration Record (MAR) revealed an order for [NAME] thyroid tablet 90 milligrams (mg) to be administered once every other day starting 09/20/22 and an order for [NAME] thyroid 60 mg to be administered once every other day starting 09/21/22. Review of a pharmacy packing slip dated 09/18/22 revealed four of each of the [NAME] thyroid doses were delivered to the facility. Further review of the September 2022 MAR revealed five doses of the [NAME] thyroid 60 mg was administered and six doses of the [NAME] thyroid 90 mg was administered. Review of the October 2022 MAR indicated coding to see nurse notes for the administration of [NAME] thyroid 60 mg scheduled 10/01/22 and 10/03/22. Coding for the administration of [NAME] thyroid 90 mg scheduled 10/02/22 indicated to see nurse notes. There were no notes regarding the [NAME] thyroid. On 10/04/22 at 2:32 P.M., observations of the facility's medication dispensing machine with the Director of Nursing (DON) revealed the [NAME] thyroid was not available. During review of pharmacy delivery records with the DON on 10/05/22 at 8:30 A.M., the DON verified the pharmacy had only delivered four doses of each of the thyroid pills on 09/18/22 and the medication was not available in the facility's medication dispensing machine. The DON was unable to explain the rationale behind the MAR indicating the [NAME] thyroid was administered with greater frequency than the medication made available by pharmacy. On 10/05/22 at 9:04 A.M., Licensed Practical Nurse (LPN) #133 stated nurses had kept calling the pharmacy about the medication because Resident #185 was very upset about it not being available. Review of the facility's Medication Ordering and Receiving From Pharmacy policy (revised August 2014) indicated if medications were not automatically refilled by the pharmacy, medications should be reordered five days in advance of need to assure an adequate supply was on hand. On 10/06/22 at 11:25 A.M., Pharmacy Representative #213 verified only four doses of the [NAME] thyroid 60 mg and four doses of the [NAME] thyroid 90 mg were sent to the facility on [DATE], indicating those doses would not have been sufficient to administer the ordered medications through the end of 365604 Page 18 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few September. Pharmacy Representative #213 stated he had no record of the [NAME] thyroid 60 mg and 90 mg being reordered until a phone call was received about the 60 mg dose on 10/03/22 and the 90 mg dose on 10/04/22. 2. Review of Resident #181's medical record revealed diagnoses including anxiety disorder, depression, diverticulosis and gastroesophageal reflux disease. The admission nursing assessment indicated Resident #181 arrived 09/30/22 at 11:42 P.M. Medications ordered upon admission included celexa (antidepressant) 40 mg every morning and aciphex (reduces gastric acid secretion) 20 mg every day. Review of the October 2022 MAR revealed notes on 10/01/22 at 1:00 P.M. which indicated the celexa was ordered and the facility was awaiting delivery, 10/02/22 at 10:16 A.M. which indicated the celexa was pending delivery and 10/04/22 at 7:51 A.M. which indicated the celexa was not available. The October 2022 MAR revealed notes on 10/01/22 at 1:00 P.M. and 10/04/22 at 7:51 A.M. which indicated the aciphex was not available for administration. On 10/04/22 at 1:40 P.M., LPN #100 stated she obtained the celexa from the facility's automated dispensing machine on 10/03/22. On 10/04/22 at 1:43 P.M., LPN #190 verified she had not administered the celexa or aciphex to Resident #81 because it was not available. On 10/04/22 at 2:32 P.M., the DON stated if a medication was not available staff could check the automated medication dispensary machine to determine if medication was available in it and pull the medication from the machine. If not, they could notify pharmacy and have medication drop shipped within four hours. Observations of the machine with the DON revealed celexa was one of the medications available. Aciphex was not available in the machine. On 10/05/22 at 8:30 A.M., the DON stated she contacted pharmacy about the aciphex and was told the order was diverted to house stock but the information was not communicated to the facility and the aciphex was not available in the medication dispensing machine. The aciphex was not delivered to the facility by pharmacy. Review of the facility's Medication Ordering and Receiving From Pharmacy policy (revised August 2014) indicated when calling, faxing, or sending medication orders for a newly admitted resident electronically, the facility needed to indicate whether a new supply of medication was needed from the pharmacy. On 10/06/22 at 11:25 A.M., Pharmacy Representative #213 stated the celexa and aciphex had been marked for profile only when the orders were sent so the pharmacy did not deliver the medications. The aciphex was sent on 10/04/22 after clarification with the facility. If the orders had been coded correctly the medications could have been expected the afternoon following admission unless they were ordered stat and could have been delivered sooner. This deficiency substantiates Complaint Number OH00136312. 365604 Page 19 of 20 365604 10/06/2022 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, interview, and review of product information, the facility failed to properly disinfect equipment being removed from a resident's room who had a diagnosis of clostridium difficile. This had the potential to affect eight residents (#18, #19, #28, #80, #184, #186, #230, and #280) of 93 residents. Residents Affected - Some Findings include: Review of Resident #35's medical record revealed she was in isolation for clostridium difficile. On 10/03/22 at 11:02 A.M. two staff were observed donning personal protective equipment and entering Resident #35's room. At 11:04 A.M., an unidentified staff member pushed a mechanical lift into the hallway and wiped it down with a ReadyKleen wipe. At 11:05 A.M. State Tested Nurse Aide (STNA) #172 exited the room pushing a reclining dialysis chair into the hall. After changing her mask and performing hand hygiene, STNA #172 returned and stated she had to disinfect the chair using ReadyKleen wipes. Review of the label for the ReadyKleen wipes did not indicate it was effective against clostridium difficile. Interview on 10/03/22 at 3:02 P.M. with the Director of Nursing verified the ReadyKleen wipes were not effective against clostridium difficile, stating she had provided the correct wipes and had the equipment recleaned. Review of the manufacturer information for Dermarite ReadyKleen wipes did not reveal it was effective against clostridium difficile. The facility identified seven additional residents (#18, #28, #80, #184, #186, #230, and #280) who could potentially use the dialysis chair and one additional resident who could potentially use the mechanical lift (#19). 365604 Page 20 of 20