Health inspection·February 21, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of a facility self-reported incident (SRI) and investigation, review of a police report, review of emergency medical service (EMS) report, review of the hospital reports, review of the facility's Abuse/Neglect policy and procedure, and interviews with the police, family, and staff, the facility failed to ensure Resident #109, who was admitted to the facility for abdominal surgical wound care was free from a situation of neglect when facility staff failed to provide appropriate and timely wound treatment, care, and services. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and medical emergency on 02/03/04 when Resident #109 and her family identified delayed and improper wound care resulting in the family's call to local police for a welfare check. Upon police arrival (on 02/03/04 beginning at approximately 12:00 P.M.) the resident's call light was activated for staff assistance and police identified significant concerns with the resident's care and overall condition which included the resident's use of blankets/towels for wound care. Upon initial investigation by police, Licensed Practical Nurse (LPN) #301 and Activities Director #405 (the facility manager on duty) indicated the facility had received two new admissions and were short-staffed resulting in Resident #109 having to wait for care. In addition, LPN #301 indicated the facility did not have the proper dressing supplies to care for the wound. Police contacted Emergency Medical Services (EMS) and the resident was subsequently transferred to the hospital with the facility documenting Resident #109 was an urgent transfer (to the hospital) because the welfare and needs of the resident could not be met in the facility. Upon arrival to the hospital on [DATE], Resident #109 was assessed to require abdominal surgical wound care and was assessed to have additional areas of skin impairment. Resident #109 reported facility staff did not assist her with going to the bathroom or provide care for the bodily fluids that were draining. The hospital noted the facility's inability to properly care for and manage the resident's wound care placed Resident #109 at risk for recurrent wound infections, severe sepsis, and increased Resident #109's morbidity and mortality. As a result of the incident, there was an open police investigation with possible criminal charges being pursued. This affected one resident (#109) of three residents reviewed for abuse and neglect. The facility census was 104. On 02/16/24 at 9:51 A.M., the Administrator, Director of Nursing (DON), Clinical Service Manager #505, and Clinical Service Manager #400 were notified Immediate Jeopardy began on 02/03/24 when Resident #109 was transferred to the hospital due to a lack of timely and necessary wound care identified by Resident #109, who was alert and oriented, and the resident's family. The resident was admitted to the hospital with worsening of an abdominal surgical wound. The lack of timely and necessary wound care placed the resident at risk of infection, severe sepsis, complications for healing, and increased Resident #109's morbidity and mortality. The Immediate Jeopardy was removed on 02/16/24 when the facility implemented the following Page 1 of 15 365611 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 corrective actions: Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few • On 02/03/24, Resident #109 was transferred to the hospital and did not return to the facility. On 02/16/24 at 3:30 P.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting and Immediate Jeopardy (IJ) Review was held with the Administrator, Regional Clinical Services Managers #505, and Medical Director #600 to review the facility polices for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, Change in Condition, and Completion of Wound Care. No policy changes were made as a result of the review. • On 02/16/24 at 3:30 P.M., the Chief Clinical Nursing Officer #506 and Regional Clinical Services Manager #505 educated the Administrator and DON on Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, Change in Condition, and Completion of Wound Care policies. • On 02/16/24, the Administrator and DON educated administrative staff, which included ADON #306, ADON #196, Human Resources Director #600, Licensed Social Worker (LSW) #222, admission Director #601, Business Office Manager #288, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #187, MDS LPN #322, Dietary Manager #602, Maintenance Director #603, Housekeeping Manager #604, Activities Director #405, Central Supply/Scheduler #605, and Medical Records #606, on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, including how to identify and prevent situations of neglect, identification of change in condition, including how to timely identify situations when care cannot be or is not provided to residents in the facility to know when to seek medical attention, and completion of wound care per orders. • On 02/16/24, ADON #306, ADON #196, Human Resources Director #600, Licensed Social Worker (LSW) #222, admission Director #601, Business Office Manager #288, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #187, MDS LPN #322, Dietary Manager #602, Maintenance Director #603, Housekeeping Manager #604, Activities Director #405, Central Supply/Scheduler #605, and Medical Records #606 educated all direct care staff on policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. The facility implemented a plan for any remaining staff not educated to be removed from the schedule after 02/16/24, pending completion of the mandatory education. Education completed included 27 nurses, 47 state tested nursing aides (STNA), one activity staff, 23 therapy, 12 environmental services staff (housekeeping, laundry, and maintenance), and 12 dietary staff. • On 02/16/24, the Administrator, DON, and Regional Clinical Services Manager #505 educated all licensed nurses on the facility policies for Change in Condition and Completion of Wound Care. For residents admitted after hours/weekends, staff would notify the clinical on-call manager to double check 365611 Page 2 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that treatments were in place and supplies were available and the resident was placed on the list to be seen by the wound certified nurse practitioner (CNP) on the next visit. A wound nurse practitioner from Wound Care Consultants visited the facility every Thursday. When a nurse identified a new skin issue with a resident, the nurse must complete necessary assessments, and contact the facility wound nurse, Assistant Director of Nursing (ADON) #306. If the wound nurse was not in the facility, the nurse would call the on-call clinical nurse manager, and the resident's physician to receive necessary orders. An on-call clinical manager is always available. • On 02/16/24, Central Supply #605 and the Administrator were educated by Chief Clinical Officer #506, on the ordering process, the ability to have deliveries STAT/same day, how to contact vendors as needed for supplies, and keeping stock in house and available to clinical staff. If all efforts to obtain wound supplies fail, the nursing staff would notify the resident's physician to review current orders and provide new orders as needed based on availability of supplies. • On 02/16/24, the DON, ADON #306, ADON #196, MDS LPN #187, and MDS LPN #322 completed head-to-toe body assessments on all 106 current residents to ensure no evidence of negligence in care resulting in skin impairments had occurred. The head-to-toe assessments included recently admitted Residents #15, #99, and #104. The appropriately assigned clinician was made aware of any change of conditions. • On 02/16/24, DON, ADON #306, ADON #196, MDS LPN #187, and MDS LPN #322 interviewed all 106 current residents regarding adequate care and treatment and if they felt safe in the facility. • On 02/16/24, DON, ADON #306, ADON #196, MDS LPN #187, and MDS LPN #322 reviewed all 106 current residents to ensure all residents remained at their psychosocial baseline. The assessment included observation for changes in mood or behaviors, and discussion with the LSW #222 regarding any new changes. • On 02/16/24, the Administrator completed an audit of all wound care supplies in the facility to ensure adequate supplies were onsite to provide the necessary care for Residents #16, #18, #28, #30, #33, #34, #44, #51, #58, #67, #75, #84, #92 #113, and #115 (those residents with current wound care orders). • On 02/16/24, Staffing Agency #500 was made aware of the neglect allegations involving LPN #401. LPN #401 was placed on the Do Not Return list. • 365611 Page 3 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 02/16/24, the SRI that was filed on 02/05/24 related to the incident with Resident #109 was updated to reflect additional interviews regarding staff involved in the resident's care. The Administrator submitted an addendum to the SRI upon review of the police report on 02/16/24. • Beginning 02/16/24, an ongoing audit would be completed by the DON/Designee daily for four weeks, then randomly thereafter. Audits would include ensuring all wound care was provided per physician's order, timely identification of changes in condition, ensuring adequate supplies were available to provide necessary care, and ensuring identification and prevention of situations of neglect for all residents. Although the Immediate Jeopardy was removed on 02/16/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #109 revealed the resident was admitted to the facility on [DATE] and discharged on 02/03/24 to the hospital. Resident #109 had diagnoses including surgical aftercare following surgery on the digestive system, colostomy, gastrostomy, protein-calorie malnutrition, anxiety, fistula of intestine, and parastomal hernia without obstruction or gangrene. Review of hospital wound documentation dated 01/29/24 at 12:55 P.M. (from the resident's hospitalization prior to admission) revealed Resident #109 had wounds located on midline abdomen incision/fistula and left lower quadrant end colostomy. The wound measured 20.5 centimeters (cm) long, 16 cm wide, and 4.5 cm deep. There was a moderate amount of yellow drainage. The wound was pink, moist with a scant amount of yellow slough, and the stoma was pink and moist. The peri wound was pink and painful. Resident #109's skin and wound were to be cleansed gently with Dial soap and water (no bath wipes) and dried thoroughly. Cavilon (breathable, waterproof moisture barrier) skin prep was to be applied to peri wound. Eakin Horizontal and Vertical wound pouches (flexible pouches designed to offer skin protection and contain drainage from wounds, fistulas and difficult stoma sites) should be cut slightly larger than wound opening. Pre-warm pouches prior to application and seal one side of each pouch edge together to form one pouch. Barrier ring strips were to be applied to skin creases to create a flat pouching surface. Apply the wound pouches over the midline fistula and colostomy and apply pink tape to the pouch edges. Hold the pouch in place with hands for two to three minutes to warm it up after application to ensure a good seal. The pouch was to be emptied when a third to half full. The pouch should be checked every four hours and document output. Pouches need to be changed when leaking and do not reinforce. The pouches should be changed every seven days or as needed for leakage. Resident #109 to continue care as described above at discharge. The discharge instructions included a phone number for any ongoing problems or concerns Monday through Friday from 8:00 A.M. to 4:30 P.M. If there were questions or concerns during evening, weekends, or holidays another phone number and instructions were provided to reach an on-call doctor for Trauma/Acute Care surgery. Review of the nursing note dated 02/01/24 at 9:13 P.M. revealed Resident #109 was admitted to the facility. Resident #109 was alert and able to make her needs known. The note indicated the dressing to the resident's abdominal fistula was intact and loose yellow drainage was observed in the drain bag. 365611 Page 4 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety The nursing note dated 02/02/24 at 11:18 A.M. revealed a 24-hour skin assessment was completed for Resident #109. Resident #109 had a significant surgical trauma to abdomen extending into right and left abdominal quadrants. The wound measured 20 cm long, 17 cm wide, and five cm deep. A previous ostomy opening, and small fistula were noted to left lower quadrant. Resident #109 had Eakin drainage pouch ordered for treatment. The note indicated the pouch was dislodged and was replaced by the nurse. No other skin alterations were noted. Residents Affected - Few Review of Nurse Practitioner's (NP) #502 note dated 02/02/24 at 2:37 P.M. revealed Resident #109 was being seen per the request of a nurse for dressing change assistance. Resident #109 was lying in bed with dressing to wound dislodged. NP #502 gave a one-time order for Oxycodone (opioid for moderate to severe pain) five milligrams (mg) to be administered now (02/02/24). Resident #109 was educated on the importance of pain management as well as the relation of dressing changes if necessary. Resident #109's nurse and ADON #306 were at the bedside for assistance. Resident #109 tolerated the dressing change. The nursing note dated 02/02/24 at 3:25 P.M. revealed Resident #109's drain pouch was dislodged. NP #502 assisted with the pouch replacement and wrote updated orders to border wound with a foam dressing prior to applying drainage pouch and for the dressing to be changed only by NP. The note included the nurse could reinforce as needed for dislodgement and/or leaking. Review of a physician's order dated 02/02/24 at 4:40 P.M. revealed a NP was the only one to complete dressing changes for Resident #109. The wound was to be cleansed only with normal saline and patted dry. CeraRing Barrier ring (to help prevent leakage and infused with Cereamide [waxy lipid molecules] to protect the skin) cut in half to left lower border of abdominal surgical incision. Silicone foam to be cut to fit the excoriated skin surrounding the abdominal surgical incision to create an occlusive dressing every Thursday and as needed for wound care. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the staff assessment for Resident #109 reflected the resident's short-term and long-term memory were intact. Resident #109 was independent with cognitive skills for daily decision making. Resident #109 had an ostomy and was occasionally incontinent of urine. Resident #109 required substantial/maximal assistance from staff with toileting hygiene, and partial/moderate assistance from staff to roll left and right. Resident #109 had a surgical wound. The nursing note dated 02/03/24 at 8:45 A.M. revealed Resident #109's wound pouch was loose at the bottom and a small bowel movement was noted. The nurse applied a new bandage to the bottom of the wound pouch. No leakage of bowel movement was noted from the wound pouch after the new bandages were applied. The nursing note dated 02/03/24 at 10:00 A.M. revealed a medium amount of stool was noted in Resident #109's wound pouch. The nurse removed the stool from the wound pouch. No pain or discomfort was noted. The nursing note dated 02/03/24 at 10:11 A.M. (created on 02/14/24 at 10:23 A.M.) revealed Resident #109 was given a Notice of Transfer and Bed Hold upon being sent to the hospital. Resident #109 was transferred because the welfare and needs of Resident #109 could not be met in the facility. The transfer was urgent because an emergency existed in which Resident #109's urgent medical needs necessitated an immediate transfer. The nursing note dated 02/03/24 at 4:19 P.M. revealed Resident #109 had been given scheduled medications and bandages had been applied to the bottom of wound pouch. Resident #109 had given as needed 365611 Page 5 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pain medication for discomfort and pain of the wound. Resident #109 decided to call EMS without notifying staff. EMS transported Resident #109 to the hospital. Review of the e-Interact situation, background, assessment, recommendation (SBAR) summary for providers dated 02/03/24 at 6:25 P.M. revealed Resident #109 had a change in condition to skin wound/ulcer. Resident #109's wound continued to be complicated due to size, fistula leaking stool into the wound bed, and compromised peri-wound. All wound complications were present upon admission. Primary care provider recommendations were to reinforce dressing and continue to monitor. Review of the medical record from 02/01/24 to 02/03/24 revealed Resident #109 did not have any behaviors including any rejection of care or non-compliance with care. Review of the case report summary from the local (Westerville) police reflecting an incident that occurred on 02/03/24 from 3:00 A.M. to 12:11 P.M. revealed a family member asked for a well-being check for Resident #109. The family member reported Resident #109 had been in their own filth for over seven hours and staff were not providing care. Resident #109 reported they had been denied assistance with an open wound. Three officers arrived at the facility and advised the receptionist they were there to speak to Resident #109. The receptionist seemed to be frustrated and began walking down the hall. While walking to Resident #109's room, it was noted Resident #109's call light was one of only two lights activated in the hallway. The officers were asked to stand outside Resident #109's door. An officer overheard staff ask Resident #109 if they had called the police. Resident #109 stated a family member called because Resident #109 was being neglected. An employee came out of Resident #109's room and told the officer not to enter because they needed to get a blanket to cover Resident #109. Upon entering Resident #109's room, Resident #109 was observed lying flat on her back with multiple blankets covering their waist and midsection. Resident #109 stated she had been admitted to the facility on [DATE] and had been lying in their own filth for 10 hours and had been asking for help. Resident #109 stated the nurse had been in to give medications multiple times but never cleaned the abdominal wound. Resident #109 stated multiple people had entered the room and told Resident #109 to wait to get help. Resident #109 showed two officers the wound and condition Resident #109 had been left in. The wound was covered by a blanket soaked in bodily fluids from the wound. The open wound began near Resident #109's belly button and went to Resident #109's ribcage. The skin surrounding the opening was bright pink in color, spreading outward from the wound. The fluid appeared to be yellow in color and smelled like feces. A lump of feces about the size of a grapefruit with the consistency of cottage cheese was sitting on Resident #109's lower stomach and the inside of the wound and was not contained in the medical bag that was in place. While talking with Resident #109, a male employee looked in the room and asked if anything was needed. It was later discovered the male employee was Resident #109's nurse. The nurse was LPN #401, who worked as a travel nurse. Resident #109 also advised the officers a similar incident was reported on Thursday/Friday. Two officers went out of Resident #109's room to talk to LPN #401. LPN #401 stated they did not neglect Resident #109 for 10 hours as Resident #109 claimed. LPN #401 indicated he was working 7:00 A.M. to 7:00 P.M. LPN #401 stated Resident #109's medical treatment required a specific medical bag and the hospital had only provided the facility with three bags when Resident #109 was admitted . LPN #401 stated they did not have any more medical bags and because it was the weekend, more bags could not be obtained from the pharmacy. LPN #401 was asked if it would be beneficial for Resident #109 to be transported to a hospital due to the facilities inability to properly care for Resident #109. LPN #401 stated he could not request Resident #109 be transported to the hospital without a supervisor's approval. LPN #401 stated he had been in contact with Resident #109's doctor and NP. LPN #401 stated Resident #109's current condition was due to a surgery the resident had. LPN #401 also stated because there 365611 Page 6 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few had been two unexpected new admissions and the facility was short staffed, LPN #401 told Resident #109 she would have to wait until someone was available to clean her. LPN #401 claimed Resident #109's current condition did not reach the level to be considered an emergency that required transportation to the hospital. One of the officers on scene recommended medics be dispatched to the scene to evaluate Resident #109. Medics and the Battalion Chief were dispatched to the scene. While waiting for the medics, the acting manager (Activities Director #405) of the facility came to talk to the officers. Activities Director #405 explained Resident #109 was told to wait because there were two new admissions the nurse was busy with. LPN #401 was standing next to Activities Director #405 and stated they had been in to see Resident #109 to deliver medications to ease Resident #109's pain. LPN #401 also stated on 02/02/24, he had been with the doctor and NP (actually was NP and ADON #306) to learn how to properly care for Resident #109's wound without the use of the specific bags sent from the hospital. Medics arrived on scene and were advised of the situation with Resident #109. The medics entered Resident #109's room and shortly afterwards one medic exited the room and advised the officers and staff that Resident #109 was being transported to the hospital. The medic also advised staff that a formal complaint would be filed. LPN #401 and Activities Director #405 went about their business within the facility. The Battalion Chief arrived on the scene and went to Resident #109's room to investigate. The Battalion Chief spoke with staff (redacted) about the state Resident #109 was in and any statements the staff wanted to make. Staff (redacted) claimed Resident #109 was disoriented. A contact at the Attorney General's (AG) Office was contacted on 02/03/24 at 1:30 P.M. The police were advised to complete their investigation and the special agent at the AG office would assist where possible. An officer spoke with Resident #109 on the telephone after Resident #109 was transported to the hospital. Resident #109 stated the hospital staff were appalled at her medical state and pictures were taken to document Resident #109's condition. Resident #109 reported she had an infection she was currently being treated for. Resident #109 stated she wanted to press charges for neglect. The report also provided a summary of notable points and times from body worn camera footage on 02/03/23 as follows: • At 12:14 P.M., the call light for Resident #109's room was on/illuminated. • At 12:16 P.M., Resident #109 stated a call had also been placed (to police) on Thursday (02/01/24) asking for assistance. • At 12:18 P.M., Resident #109 stated she was constantly told by staff they would be back. Resident #109 believed she had not been tended to since 3:30 A.M. • At 12:23 P.M., Resident #109 was asked some basic questions to help gauge awareness (date, time, location, etc). Resident #109 answered all questions correctly without any apparent issues. • At 12:26 P.M., Resident #109 was asked about any prior issues at the facility. Resident #109 365611 Page 7 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety reported on the day of admission [DATE]) she needed cleaned up from the trip from the hospital and had been at the facility for hours without anything being done. • At 12:33 P.M., medics were called with a request for the Battalion Chief to also come to the facility. Residents Affected - Few • At 12:38 P.M., Resident #109 stated feces had been on her open wound for nine hours. • At 12:39 P.M., Resident #109 was asked if she had notified anyone during the nine hours. Resident #109 held up the nurse call button and said that she did constantly. • At 12:40 P.M., a medic came in, took one look at Resident #109's opened wound area and said they needed to get Resident #109 to the hospital. • From 12:48 P.M. to 12:49 P.M., Activities Director #405 was overheard telling other officers and Battalion Chief that Resident #109 was confused. This officer reported Resident #109 had been asked questions related to awareness and Resident #109 had answered correctly. Review of the EMS report dated 02/03/24 revealed at 12:39 P.M., EMS arrived at Resident #109's bedside. Resident #109 was alert and oriented times four and had bowel/stomach contents spilling from seal around abdomen surgery area. The area was red and warm, and appeared possibly infected. Resident #109 stated she had been resting in spilled contents for approximately nine hours and staff would not help remedy the situation. EMS transported Resident #109 to the hospital at 12:53 P.M. Review of the hospital records dated 02/03/24 revealed Resident #109 had an extensive history of abdominal surgeries, multiple colostomy revisions, fistulous tracks, and perforation. Resident #109 was discharged from the hospital to a facility on 02/01/24. Resident #109 stated she had been lying in their own feces and drainage from the wound for the past five days. The police were called to the facility. Resident #109 had a complicated abdominal surgical history now with a recurrent postoperative wound infection. It appeared the outpatient facilities were unable to care for this complex wound. It was likely in the best interest of Resident #109 to remain hospitalized until her wound could be appropriately cared for at an outpatient facility. The inability of the skilled facility to provide adequate wound care, placed Resident #109 at risk for recurrent wound infections, severe sepsis and increased Resident #109's morbidity and mortality. Resident #109's abdominal wall inferior to the wound looked significantly erythematous (redness) likely secondary to irritation and cellulitis from succus (fluid secretions) and feculent (waste) output. A computed tomography (CT) scan of abdomen/pelvis on 02/03/24 at 5:26 P.M. compared to the previous CT on 01/13/24, revealed the abdominal wound had worsened. Review of photos taken at the hospital revealed Resident #109's skin was very red from the bottom of the wound to the mons pubis. An additional photo showed redness to Resident #109's 365611 Page 8 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few upper right thigh and a white dried substance to Resident #109's right groin. Another photo revealed Resident #109's buttocks were reddened. A photo showed Resident #109's left heel was dry, cracked and reddened. A photo also revealed a reddened area under Resident #109's left breast. Review of the emergency department notes by a Licensed Social Worker (LSW) dated 02/03/24 at 4:07 P.M. revealed the LSW spoke with Resident #109 about concerns for neglect at the skilled facility. Resident #109 reported she was placed in skilled facility from 02/01/24 to 02/03/24. Resident #109 reported she was unable to ambulate or toilet without assistance. Resident #109 reported lying in bed for about 12 hours on 02/02/24 with a call light on asking for assistance to go to the bathroom and have the wound cleaned. Resident #109 reported when no one showed up to help, Resident #109 used blankets, pillows, and sheets to clean the wounds. Resident #109 reported lying in feces and urine for long periods of time. Resident #109 had contact with a family member. On 02/03/24, Resident #109's family called the police and Resident #109 was transported to the hospital. This case had been reported to the police, adult protective services, department of health, and hospital case management given Resident #109 was covered in feces for four days. Review of the facility self-reported incident (SRI), tracking number 243820 dated 02/05/24 revealed there was an allegation of neglect that occurred on 02/03/24 at 10:00 A.M. when Resident #109's family/friend called 911. Police officers arrived on 02/03/24 around 12:00 P.M. and asked to speak with Resident #109. Officer #542 spoke with Resident #109 and facility staff. The SRI included Officer #542 was aggressive toward LPN #401 and raised her (actually a male officer) voice at LPN #401 in the hallway, asking what was going on with Resident #109 and that they were taking Resident #109 to the hospital. The facility documented in the SRI that officers and EMS did not explain to anyone what was going on and what the complaint was about. On 02/03/24, the DON called the police department to find out what was going on and why Officer #542 yelled at LPN #401. The DON called on 02/05/24 and was given a report number. LPN #401 stated Resident #109 was putting tissue paper onto her wound and was taking the dressing off. LPN #401 and State Tested Nursing Assistant (STNA) #184 stated they were in the resident's room multiple times for the day helping and educating Resident #109 not to mess with the wound. Review of the written statement by STNA #184 dated 02/03/24 revealed they received report at 7:00 A.M. Resident #109 was sleeping when the report was given. Resident #109 refused breakfast and lunch. Resident #109 was encouraged to eat breakfast but stated she was not hungry. Resident #109's call light was on and STNA #184 found soiled linens with feces on the floor. STNA #184 picked up the soiled linens and gave Resident #109 new linens. Housekeeping cleaned the floor. Resident #109's call light was on, and Resident #109 stated she wanted the nurse. STNA #184 notified LPN #401. Later, STNA #184 saw three police officers asking for Resident #109. Resident #109 refused care when the officers came in the room and said she did not want to be cleaned or touched. A written statement by LPN #401 dated 02/03/24 (no time) revealed Resident #109 was given morning medications and the resident's wound was assessed. The wound bandage was loose at the bottom and LPN #401 applied new bandages to the bottom of the wound. Resident #109 was using tissue and other random linen for self-care of the wound. LPN #401 educated Resident #109 about infection by using tissue and linen sheets inside of wound. Resident #109 was educated about using call light. The call light came on and STNA #184 answered the call light. STNA #184 notified LPN #401 that Resident #109 would like to speak to LPN #401. LPN #401 told STNA #184 he would be there as soon as possible. STNA #184 and housekeeping were in Resident #109's room. LPN #401 went into Resident #109's room and the bandage was loose at bottom. LPN #401 applied a new seal on the bandage. Resident #109 requested a pain pill for discomfort and pain. Resident #109 was given as needed pain 365611 Page 9 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the police report, review of the Emergency Medical Services (EMS) report, review of the hospital records, review of the facility's self-reported incident (SRI), staff interview, and facility policy review, the facility failed to timely report an allegation of resident neglect to the State Survey Agency, the Ohio Department of Health. This affected one (Residents #109) of three residents reviewed for abuse. The facility census was 104. Findings include: Review of the closed medical record for Resident #109 revealed the resident was admitted to the facility on [DATE] and discharged on 02/03/24 to the hospital. Resident #109 had diagnoses including surgical aftercare following surgery on the digestive system, colostomy, gastrostomy, protein-calorie malnutrition, anxiety, fistula of intestine, and parastomal hernia without obstruction or gangrene. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the staff assessment for Resident #109 reflected the resident's short-term and long-term memory were intact. Review of the case report summary from the local police (Westerville) for an incident that occurred on 02/03/24 from 3:00 A.M. to 12:11 P.M. revealed a family member asked for a well-being check for Resident #109. The family member reported Resident #109 had been in their own filth for over seven hours and staff were not providing care. Resident #109 reported they had been denied assistance with an open wound. An officer overheard staff ask Resident #109 if they had called the police. Resident #109 stated a family member called because Resident #109 was being neglected. Resident #109 stated they had been admitted to the facility on [DATE] and had been lying in their own filth for 10 hours and had been asking for help. Resident #109 stated the nurse had been given medications multiple times but never cleaned the abdominal wound. Resident #109 stated multiple people had entered the room and told Resident #109 to wait to get help. Licensed Practical Nurse (LPN) #401 stated they did not neglect Resident #109 for 10 hours as Resident #109 claimed. LPN #301 stated Resident #109's medical treatment required a specific medical bag and the hospital had only provided the facility with three bags when Resident #109 was admitted . Officers asked LPN #401 if it would be beneficial for Resident #109 to be transported to a hospital due to the facilities inability to properly care for Resident #109. LPN #401 stated they would have to get permission from a supervisor to send Resident #109 to the hospital. LPN #401 had told Resident #109 they would have to wait until someone was available to clean Resident #109 because there had been two unexpected admissions and the facility was short staffed. One of the officers on scene recommended medics be dispatched to the scene to evaluate Resident #109. Medics and the Battalion Chief were dispatched to the scene. The medics entered Resident #109's room and shortly afterwards one medic exited the room and advised the officers and staff that Resident #109 was being transported to the hospital. The medic also advised staff that a formal complaint would be filed. Review of the EMS report dated 02/03/24 revealed at 12:39 P.M., EMS arrived at Resident #109's bedside. Resident #109 was alert and oriented times four and had bowel/stomach contents spilling from seal around abdomen surgery area. The area was red and warm, and appeared possibly infected. Resident #109 stated she had been resting in spilled contents for approximately nine hours and staff would not help remedy the situation. EMS transported Resident #109 to the hospital at 12:53 P.M. 365611 Page 10 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the hospital records dated 02/03/24 revealed Resident #109 had an extensive history of abdominal surgeries, multiple colostomy revisions, fistulous tracks, and perforation. Resident #109 was discharged from the hospital to a facility on 02/01/24. Resident #109 stated she had been lying in their own feces and drainage from the wound for the past five days. The police were called to the facility. Resident #109 had a complicated abdominal surgical history now with a recurrent postoperative wound infection. It appeared the outpatient facilities were unable to care for this complex wound. It was likely in the best interest of Resident #109 to remain hospitalized until her wound could be appropriately cared for at an outpatient facility. The inability of the skilled facility to provide adequate wound care, placed Resident #109 at risk for recurrent wound infections, severe sepsis and increased Resident #109's morbidity and mortality. Resident #109's abdominal wall inferior to the wound looked significantly erythematous (redness) likely secondary to irritation and cellulitis from succus (fluid secretions) and feculent (waste) output. A computed tomography (CT) scan of abdomen/pelvis on 02/03/24 at 5:26 P.M. compared to the previous CT on 01/13/24, revealed the abdominal wound had worsened. Review of photos taken at the hospital revealed Resident #109's skin was very red from the bottom of the wound to the mons pubis. An additional photo showed redness to Resident #109's upper right thigh and a white dried substance to Resident #109's right groin. Another photo revealed Resident #109's buttocks were reddened. A photo showed Resident #109's left heel was dry, cracked and reddened. A photo also revealed a reddened area under Resident #109's left breast. Review of the emergency department notes by a Licensed Social Worker (LSW) dated 02/03/24 at 4:07 P.M. revealed the LSW spoke with Resident #109 about concerns for neglect at the skilled facility. Resident #109 reported she was placed in skilled facility from 02/01/24 to 02/03/24. Resident #109 reported she was unable to ambulate or toilet without assistance. Resident #109 reported lying in bed for about 12 hours on 02/02/24 with a call light on asking for assistance to go to the bathroom and have the wound cleaned. Resident #109 reported when no one showed up to help, Resident #109 used blankets, pillows, and sheets to clean the wounds. Resident #109 reported lying in feces and urine for long periods of time. Resident #109 had contact with a family member. On 02/03/24, Resident #109's family called the police and Resident #109 was transported to the hospital. This case had been reported to the police, adult protective services, department of health, and hospital case management given Resident #109 was covered in feces for four days. Review of self-reported incident (SRI) #243820 dated 02/05/24 revealed there was an allegation of neglect that occurred on 02/03/24 at 10:00 A.M. when Resident #109's family/friend called 911. Police officers arrived on 02/03/24 around 12:00 P.M. and asked to speak with Resident #109. Officer #542 spoke with Resident #109 and facility staff. On 02/03/24, the Director of Nursing (DON) called the police department to find out what was going on and why Officer #542 yelled at LPN #401. DON called on 02/05/24 and was given a report number. Interview on 02/18/24 at 11:14 A.M. with the DON verified a SRI regarding allegations of neglect for Resident #109 was not reported to the State Survey Agency until two days later on 02/05/24. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy and procedure dated 11/30/23 revealed all incident and allegations of abuse and neglect must be reported immediately to the Administrator or designee. The Administrator or his/her designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect and abuse as soon as possible, but in no later than 24 hours from the time the incident/allegation was made known to a staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. 365611 Page 11 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0609 This was an incidental finding during the course of the complaint investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365611 Page 12 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and policy review, the facility failed to timely treat a resident's pressure ulcers when they were first identified. This affected one (Resident #111) of three residents reviewed for wounds. The facility census was 104. Residents Affected - Few Findings include: Review of the closed medical record revealed Resident #111 was admitted on [DATE] and left the facility against medical advice (AMA) on 01/22/24. Diagnoses included spinal stenosis, type II diabetes mellitus, bipolar disorder, mood disorder, convulsions, and cervicalgia. Review of the nursing note dated 01/19/24 (Friday) at 5:01 P.M. revealed Resident #111 had a pressure wound to coccyx that measured 2.5 centimeters (cm) long and 0.7 cm wide. Resident #111 also had a pressure wound to the right upper buttock that measured 1.5 cm long and one cm wide. Resident #111 had a pressure wound to the left buttock that measured 1.5 cm long and 0.8 cm wide. Resident #111 had a scabbed wound to right groin and a pressure wound to right lower chest that measured 0.5 cm long and 1.5 cm wide. There were no treatment orders for the pressure ulcers until three days later on 01/22/24. Review of the physician orders dated 01/22/24 (Monday) revealed treatment orders for Resident #111 were obtained for bilateral buttocks and bilateral groin. Resident #111's buttocks and groin were to be cleansed with soap and water, patted dry, and Zinc Oxide applied every shift and as needed. There were no treatment orders for the pressure ulcers that were identified on 01/19/24 until three days later on 01/22/24. Interview on 02/14/24 at 8:58 A.M. with Resident #111 verified they had several pressure ulcers upon admission and no treatments were completed. Interview on 02/16/24 at 12:27 P.M. with Wound Certified Nurse Practitioner (CNP) #403 verified a wound CNP did not work the weekends. Interview on 02/18/24 at 3:58 P.M. with Assistant Director of Nursing (ADON) #306 verified on 01/19/24, Resident #111 had pressure ulcers to coccyx, left buttock, right upper buttock, and right lower chest. Resident #111 also had a scabbed wound to right groin. ADON #306 verified no treatments were put in place until 01/22/24. ADON #306 also verified treatments were not put in place for Resident #111's pressure ulcer to coccyx or right lower chest. Review of the facility's Skin Care Management policy and procedure dated 06/08/22 revealed residents with identified skin breakdown will have a documented skin assessment weekly and treatments as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00150794, Complaint Number OH00150787, and Complaint Number OH00150675. 365611 Page 13 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a police report, interview with the local Fire Deputy Chief, residents and staff, review of the resident council minutes, review of emergency call records, and policy review, the facility failed to have sufficient staffing to meet the residents needs. This affected four residents (#28, #35, #58, and #109) and had the potential to affect all 104 residents currently residing in the facility. Findings include: Review of the resident council minutes dated 01/24/24 revealed call lights were not being answered timely. Review of the closed medical record revealed Resident #109 was admitted on [DATE] and discharged on 02/03/24. Diagnoses included surgical aftercare following surgery on the digestive system, colostomy, gastrostomy, protein-calorie malnutrition, anxiety, fistula of intestine, and parastomal hernia without obstruction or gangrene. Review of the case report summary from the local police (Westerville) for incident that occurred on 02/03/24 from 3:00 A.M. to 12:11 P.M. revealed a family member asked for a well-being check for Resident #109. The family member reported Resident #109 had been in their own filth for over seven hours and staff were not providing care. Resident #109 stated the nurse had been given medications multiple times but never cleaned the abdominal wound. Resident #109 stated multiple people had entered the room and told Resident #109 to wait to get help. Licensed Practical Nurse (LPN) #401 revealed there had been two unexpected new admissions and the facility was short staffed, LPN #401 told Resident #109 they would have to wait until someone was available to provide care to Resident #109. Activities Director #405 revealed they were the manager on duty and oversaw the facility for the day. Activities Director #405 explained Resident #109 was told to wait because there were two new admissions and LPN #401 was busy. A nurse note dated 02/03/24 at 10:11 A.M. (created on 02/14/24 at 10:23 A.M.) revealed Resident #109 was given a Notice of Transfer and Bed Hold upon being sent to the hospital. Resident #109 was transferred because the welfare and needs of Resident #109 could not be met in the facility. The transfer was urgent because an emergency existed in which Resident #109's urgent medical needs necessitated an immediate transfer. Interview on 02/16/24 at 10:35 A.M. with Fire Deputy Chief #402 revealed they received multiple 911 calls from the facility. Some of the calls were from residents requesting assistance because staff would not answer call lights or provide care. Fire Deputy Chief #402 stated there were times the 911 dispatcher would try to call the facility to clarify if there was an emergency. Fire Deputy Chief #402 stated often no one at the facility would answer the phone. Interview on 02/16/24 at 2:38 P.M. with Resident #58 revealed call lights could take an hour to be answered and it took a long time for staff to be able to put her to bed. Resident #58 stated the facility needed more staff to help answer call lights and provide care. Interview on 02/16/24 at 2:48 P.M. with Resident #28 revealed they had waited up to four hours for 365611 Page 14 of 15 365611 02/21/2024 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many call light to be answered. Resident #28 stated they had never called 911 to get assistance but had heard some of the residents had. Interview on 02/16/24 at 2:52 P.M. with Resident #35 revealed call lights were answered within 15 to 45 minutes. Resident #35 stated when staff did answer the call light, they were always in a hurry because they were short staffed. Interview on 02/18/24 at 11:14 A.M. with the Director of Nursing (DON) revealed the facility did not have a staffing problem. DON stated agency staff was used, there was a weekend manager in the facility for four hours every Saturday and Sunday, and there was an on-call nurse if needed. The DON verified Resident #109 was transported to the hospital due to concerns of care not being provided. On 02/19/24 at 2:06 P.M. with Fire Deputy Chief #402 provided a spreadsheet revealing between 10/01/23 and 02/16/24 there were 246 calls from the facility. Out of the 246 calls, 144 calls were identified as coming from cell phones or non-emergent calls presumably made by residents. Review of the facility's Staffing and Scheduling policy and procedure dated 06/08/22 revealed the facility would follow the Centers for Medicare and Medicaid Services (CMS) and state staffing requirements. This deficiency represents non-compliance investigated under Complaint Number OH00150794, Complaint Number OH00150787 and Complaint Number OH00150417. 365611 Page 15 of 15