Health inspection·December 6, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of a Self-Reported Incident, review of the witness statements and police report, and resident and staff interviews, the facility failed to ensure Resident #90 was treated with dignity and respect. This affected one resident (#90) of three residents reviewed for dignity and respect. The facility census was 89. Findings include: Review of the medical record revealed Resident #90 was admitted to the facility on [DATE] and discharged on 11/28/23. Resident 390 had diagnoses including cerebral infarction, aphasia, chronic pain syndrome, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had unclear speech, sometimes understood, and responded adequately to simple direct communication only. Resident #90's cognitive skills were modified independently with some difficulty in new situations and had no behaviors. Review of a facility Self-Reported Incident (SRI), tracking number 241517 dated 11/27/23 revealed the facility reported an allegation of physical abuse. Resident #69 reported State Tested Nursing Assistant (STNA) #104 held Resident #90's shoulders, asked Resident #90 if they wanted to fight and asked why Resident #90 was mad at STNA #104. STNA #104 put her fist against Resident #90's face and pushed against Resident #90's face to turn Resident #90's head. STNA #104 then sat on Resident #90's lap and started bouncing up and down. Resident #69 reported Resident #90 was visibly upset. Resident #25 was also interviewed and stated they did not see STNA #104 put their fist against Resident 90's face but observed STNA #104 bouncing on Resident #90 and felt it was abusive behavior. Resident #90's son was notified of the incident. Due to language barriers, Resident #90's son was asked if he could come to the facility to help explain what happened with Resident #90. The police were also notified. The police officer spoke with Resident #90's son. Resident #90's son was initially upset and stated he would speak with Resident #90. The facility unsubstantiated the allegation of physical abuse to Resident #90. Review of the police report dated 11/28/23 revealed Resident #90 had limited communication due to a history of a stroke and English not being Resident #90's primary language. Resident #90's son arrived and was very upset and stated he would speak with Resident #90 but Resident #90 was unable to answer open ended questions. Resident #90 verified STNA #104 had pushed her face but Resident #90 would not answer if STNA #104 bounced on Resident #90's lap. Page 1 of 8 365611 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the undated witness statement by Resident #25 revealed Resident #25 saw STNA #104 bouncing on Resident #90's lap and felt STNA #104 was abusing Resident #90. Review of the undated witness statement by STNA #104 revealed they were trying to get Resident #90 to laugh or smile. Residents Affected - Few Interview on 12/04/23 at 9:20 A.M. with Resident #69 revealed STNA #104 asked Resident #90 why she was so mad. STNA #104 put a hand on both of Resident #90's shoulders and shook Resident #90. STNA #104 then put her fist against Resident #90's face and pushed Resident #90's face. STNA #104 then sat on Resident #90's lap and bounced up and down while Resident #90 was sitting in a wheelchair. Resident #90 was crying. Resident #69 stated STNA #104 called Resident #69 crazy when he stated he felt Resident #90 was being abused. Interview on 12/06/23 at 2:48 P.M. with Resident #25 stated she witnessed STNA #104 bouncing up and down on Resident #90. Resident #25 stated Resident #90 was visibly upset. Resident #25 told STNA #104 to get off Resident #90 because Resident #90 was upset. Interview on 12/06/23 at 4:35 P.M. with the Administrator verified an SRI tracking number 241517 was reported due to concerns about Resident #90 being physically abused. The Administrator indicated Resident #90's family did not have a concern with the allegation due to the alleged perpetrator and Resident #90 were both from the same village in [NAME]. This deficiency represents non-compliance investigated under Complaint Number OH00148370. This deficiency is also an example of continued non-compliance from the survey dated 10/10/23. 365611 Page 2 of 8 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the resident council minutes, and resident and staff interviews, the facility failed to ensure the residents were bathed according to their bathing preference. This affected two residents (#69 and #70) of three residents reviewed for bathing preferences. The facility census was 89. Findings include: 1. Review of the medical record revealed Resident #69 was admitted on [DATE] with diagnoses including fracture of right femur, anxiety, and intracranial injury with loss of consciousness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact and required extensive assistance of one staff for bed mobility and personal hygiene and extensive assistance of two staff for transfers. Review of the plan of care dated 10/26/23 revealed Resident #69 was satisfied with bathing twice a week and preferred a shower. Review of the facility's shower schedule revealed Resident #69 was scheduled to be bathed during the evening shift on Tuesday and Friday. Review of the bathing documentation for the last 30-days revealed Resident #69 received a shower four times in the last 30 days on 11/09/23, 11/20/23, 11/29/23, and 12/03/23. Interview on 12/04/23 at 9:20 A.M. with Resident #69 revealed she preferred a shower over a bed bath. Resident #69 stated they were only allowed to have showers twice a week. Resident #69 stated they had gone at least seven days without a shower. Interview on 12/06/23 at 2:07 P.M. with the Director of Nursing (DON) verified Resident #69 preferred showers and was not being showered twice a week. 2. Review of the medical record revealed Resident #70 was admitted on [DATE] with diagnoses including multiple sclerosis, peripheral neuropathy, migraine, and major depressive disorder. Review of the plan of care dated 05/03/23 revealed Resident #70 preferred to be bathed in the evening and wanted showered three times a week. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact, required extensive assistance of two staff for bed mobility, and total dependence of two staff for transfers and bathing. Review of the facility's shower schedule revealed Resident #70 was scheduled to be bathed during the evening shift on Wednesday and Saturday. Review of the bathing documentation for the last 30-days revealed Resident #70 did not receive any showers. Interview on 12/04/23 at 9:01 A.M. with Resident #70 stated they were not getting bathed as scheduled. Resident #70 stated they wanted a shower, but staff gave her a bed bath instead. 365611 Page 3 of 8 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0561 Level of Harm - Minimal harm or potential for actual harm Interview on 12/06/23 at 2:07 P.M. with the Director of Nursing (DON) verified Resident #70 preferred showers and had not been showered in the last 30 days. Review of the resident council meeting minutes dated 10/18/23 revealed the residents wanted more showers instead of bed baths. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00148811. This deficiency is also an example of continued non-compliance from the survey dated 10/10/23. 365611 Page 4 of 8 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely report a resident fall, timely assess Resident #61 status post fall to prevent further falls/accidents and failed to ensure the fall was documented in the resident's medical record. This affected one resident (#61) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the medical record revealed Resident #61 was admitted on [DATE] with diagnoses including malignant neoplasm of lung, acute respiratory failure, pleural effusion, and fracture of vertebra. Review of a nurse practitioner (NP) note dated 11/29/23 at 10:53 A.M. revealed Resident #61 reported they had ongoing pain in the shoulder, but it was worse after a fall on 11/28/23. There was documentation in the medical record of Resident #61 falling on 11/28/23. Review of a Fall Review form dated 11/29/23 at 1:13 P.M. revealed the NP notified the nurse that Resident #61 reported a fall that took place on 11/28/23 around 6:00 P.M. The nurse interviewed and assessed Resident #61 on 11/29/23 at 11:15 A.M. Resident #61 stated State Tested Nursing Assistant (STNA) #100 was assisting Resident #61 from the toilet to wheelchair when Resident #61 fell between the toilet and wheelchair. Resident #61 stated they hit their right shoulder on the wheelchair. STNA #100 got STNA #101 to assist Resident #61 off the floor. STNA #100 and #101 put Resident #61 into the wheelchair and then into bed. Review of the typed statement dated 11/29/23 at 11:30 A.M. revealed STNA #100 was assisting Resident #61 from the toilet to wheelchair. Resident #61 became weak and slid to the floor between the toilet and wheelchair. STNA #100 got STNA #101 to assist with getting Resident #61 off the floor. STNA #100 reported they notified the nurse. Review of the typed statement dated 11/29/23 at 12:20 P.M. revealed STNA #101 was notified by STNA #100 they needed assistance getting Resident #61 off the floor. Resident #61 stated they were nauseated. STNA #101 notified the nurse about Resident #61's nausea. STNA #101 could not remember if they notified the nurse that Resident #61 had fallen. STNA #101 thought STNA #100 would notify the nurse. STNA #101 was educated on reporting falls even if they thought someone else had reported the fall. Review of the typed statement dated 11/29/23 at 2:04 P.M. revealed Registered Nurse (RN) #102 was not told in report the morning of 11/29/23 that Resident #61 fell. Review of the typed statement dated 11/29/23 at 3:00 P.M. revealed RN #103 (working the evening of 11/28/23) was not aware Resident #61 had a fall. Review of the plan of care dated 11/29/23 revealed Resident #61 was at risk for falls due to impaired balance and unsteady gait. Interventions included the assistance of two staff for transfers. Interview on 12/06/23 at 11:12 A.M. with the Director of Nursing (DON) verified the nurse working 11/28/23 was not notified Resident #61 had a fall and an assessment of Resident #61 was not done 365611 Page 5 of 8 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0689 Level of Harm - Minimal harm or potential for actual harm until 11/29/23. The DON verified the nurse was to be notified immediately of any falls and the resident was to be assessed for injury by a nurse prior to moving the resident. This deficiency represents non-compliance investigated under Complaint Number OH00148370. This deficiency is also an example of continued non-compliance from the survey dated 10/10/23. Residents Affected - Few 365611 Page 6 of 8 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

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 record review, review of the medication administration policy and procedure, and resident and staff interview, the facility failed to ensure controlled drug records and medication administration records were consistent and accurate to reflect the actual administration and accounting for controlled medications for Resident #69. This affected one resident (#69) of three residents reviewed for medications. The facility census was 89. Findings include: Review of the medical record revealed Resident #69 was admitted on [DATE] with diagnoses including fracture of right femur, anxiety, and intracranial injury with loss of consciousness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact. Review of the plan of care dated 09/25/23 revealed Resident #69 had pain/discomfort related to right femur and right tibia fracture. Interventions included administering pain medication and encouraged nonmedicinal interventions to control pain. The plan of care dated 10/11/23 revealed Resident #69 received pain medications. Interventions included administering medication as ordered and reviewing pain medication efficacy. Review of the controlled drug record revealed Oxycodone (opioid for moderate to severe pain) 10 mg every six hours as needed for pain. The controlled drug record revealed Oxycodone 10 mg was documented as being signed out for administration to the resident on 11/16/23 at 1:30 P.M., and 11/22/23 at 8:00 A.M. and 4:00 P.M. However, review of the corresponding MAR revealed no written documentation of the Oxycodone 10 mg being administered to the resident on 11/16/23 at 1:30 P.M. or 11/22/23 at 8:00 A.M. and 4:00 P.M. A controlled drug record revealed Oxycodone 5.0 mg every eight hours as needed for pain. The controlled drug record revealed Oxycodone 5.0 mg was documented as being signed out for administration to the resident on 11/26/23 at 3:00 P.M., 11/27/23 at 8:30 A.M., 11/27/23 at 6:00 P.M., and 11/29/23 at 8:00 A.M. However, review of the corresponding MAR revealed no written documentation of the Oxycodone 5.0 mg being administered to the resident on 11/26/23 at 3:00 P.M., 11/27/23 at 8:30 A.M., 11/27/23 at 6:00 P.M. or 11/29/23 at 8:00 A.M. Interview on 12/04/23 at 9:20 A.M. with Resident #69 revealed they did not feel like they always got their pain medication when requested or scheduled. Resident #69 stated he suspected one of the nurses taking the medication instead of administering it to them. Interview on 12/05/23 at 2:56 A.M. with the Director of Nursing (DON) verified there was missing documentation on the MAR to reflect the medication being signed out on the controlled medication sheets were actually being administered to Resident #69. 365611 Page 7 of 8 365611 12/06/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medication Administration Policy and Procedure, revised December 2019, revealed in no case should the individual who administered the medications report off-duty without first recording the administration of any medications. When as needed medications were administered, the following documentation should be documented: the date and time of administration, complaints or symptoms for which the medication was given, results achieved from giving the dose and the time results were noted, and signature or initials of person recording administering medication. This deficiency is an incidental finding discovered during the course of the complaint investigation. 365611 Page 8 of 8