Health inspection·October 29, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, staff interview and policy review, the facility failed to ensure surgical wound care was completed as ordered. This affected one (#95) out of the three residents reviewed for wound care. The facility also failed to ensure peripherally inserted central catheter (PICC) line dresses were changed as ordered. This affected two (#95 and #96) out of the three residents reviewed for intravenous (IV) or PICC line placement. The facility census was 87. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #95 revealed an admission date of 09/26/24 with medical diagnoses of chronic multifocal osteomyelitis, methicillin resistance staphylococcus aureus (MRSA), disorder of kidney and ureter, and conduct disorder. The medical record review revealed a discharge date of 10/14/24. Review of the medical record for Resident #95 revealed an admission Minimum Data Set (MDS) assessment, dated 10/02/24, which indicated Resident #95 was cognitively intact and was independent with toileting, bed mobility, and transfers. Review of the MDS revealed Resident #95 received IV medications. Review of the MDS indicated Resident #95 had a surgical wound. Review of the medical record for Resident #95 revealed hospital discharge orders dated 09/26/24 which contained an order to change dressing to PICC line weekly unless it becomes loose, damp, or soiled. Further review of the hospital discharge orders revealed an order for wound care- dressing to be removed three days after surgery and replace dry dressing daily. Review of the medical record for Resident #95 revealed an order dated 10/09/24 for wound care to right shoulder with 33 staples to apply xeroform and island dressing every other day and as needed. Review of the physician orders for Resident #95 revealed no documentation to support there was an order for surgical wound care prior to 10/09/24 or any orders for PICC line dressing change. Review of the medical record for Resident #95 revealed the September 2024 Treatment Administration Record (TAR) did not contain documentation to support the facility completed surgical wound care or PICC line dressing change as per hospital orders. Review of the October 2024 TAR revealed documentation to support wound care was completed on 10/11/24 as ordered. The October TAR did not have documentation to support the facility completed the dressing change to the PICC line as per hospital orders. Interview on 10/28/24 at 1:56 P.M. with Administrator confirmed Resident #95's medical record did not contain documentation to support Resident #95's surgical wound care or PICC line dressing was changed as per hospital discharge orders. Page 1 of 8 365616 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #97 revealed an admission date of 08/02/24 with medical diagnoses of diabetes mellitus, arthritis due to bacteria right knee, atrial fibrillation, osteomyelitis, and congestive heart failure. Review of the medical record for Resident #97 revealed an admission MDS assessment, dated 08/23/24, which indicated Resident #97 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, bathing, and bed mobility, and substantial/maximum assistance with transfers. The MDS indicated Resident #97 received IV medications. Review of the medical record for Resident #97 revealed a physician order dated 08/21/24 for PICC line dressing and cap change every seven days and as needed and to measure length of exposed tubing with each dressing change. Review of the medical record for Resident #97 revealed the August 2024 TAR contained no documentation to support Resident #97's PICC line dressing was changed as ordered on 08/28/24. Further review of the September 2024 TAR revealed no documentation to support Resident #97's PICC line dressing was changed as ordered on 09/11/24. Interview on 10/29/24 at 10:20 A.M. with Regional Clinical Support #225 confirmed the medical record for Resident #97 did not contain documentation to support the facility changed PICC line dressing as ordered on 08/28/24 and 09/11/24. Review of the facility policy titled, Dressing Change (Clean), revised 06/08/22 stated the purpose was to protect wound, prevent irritation, infection and spread of infection, and promote healing. The policy stated staff are to wash hands, apply gloves, and remove soiled dressing and discard in plastic bad and dispose of gloves, and wash hands. Apply new gloves and cleanse wound. Dispose of gloves, wash hands, and apply new gloves. Apply new glove and apply dressing as ordered. Review of the facility policy titled, Catheter insertion and care, revised November 2022, stated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-sire dressing. The policy stated to change the dressing if it became damp, loosened or visible soiled and at least every 7 days for transparent semi-permeable membrane (TSM) and at least every 2 days for sterile gauze dressing. This deficiency represents non-compliance investigated under Complaint Number OH00158773. 365616 Page 2 of 8 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

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 medical record review, staff and resident interviews, and policy review, the facility failed to ensure a new pressure ulcer was assessed, measured, and physician notified timely. This affected one (#51) out of the three residents reviewed for wound care. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #51 revealed an admission date of 10/11/24 with medical diagnoses of hypertensive heart disease, chronic kidney disease Stage III, diabetes mellitus with neuropathy, bipolar disorder, and chronic obstructive pulmonary disease. Review of the medical record for Resident #51 revealed an admission Minimum Data Set (MDS) assessment, dated 10/18/24, which indicated Resident #51 was cognitively intact and was dependent upon staff for toileting and transfers, required substantial/maximum for bating and bed mobility. The MDS indicated Resident #51 was incontinence of bladder and bowel, was at risk for skin breakdown, and no pressure ulcers were present upon admission. Review of the medical record for Resident #51 revealed physician orders dated 10/11/24 for protective skin barrier cream to peri area, pressure reducing cushion to chair, pressure reducing mattress to bed, and to turn and reposition as tolerated and as needed. Review of the medical record for Resident #51 revealed an order dated 10/14/24 to apply zinc to bilateral buttocks after each incontinence episode. Review of the medical record for Resident #51 revealed a weekly wound assessment completed 10/14/24 which indicated Resident #51 did not have any skin breakdown. Review of the weekly wound assessment dated [DATE] revealed Resident #51 had an unstageable pressure ulcer to left buttock which measured 3 centimeters (cm) by 2.5 cm with 95% slough present and new treatment was ordered. Review of the medical record for Resident #51 revealed shower/bath sheets for 10/22/24 completed by State Tested Nursing Assistant (STNA) #230 indicated Resident #51 did not have any skin breakdown. Further review of the shower/bath sheet completed 10/23/24 also indicated Resident #51 did not have any skin breakdown. Interview on 10/24/24 at 8:25 A.M. with Resident #51 revealed the resident stated had pain to her bottom because of an open sore. Interview on 10/28/24 at 3:38 P.M. with STNA #230 confirmed she gave Resident #51 a bath on 10/22/24 and stated she observed a small open area to Resident #51's buttock. STNA #230 confirmed she did not code the skin issue on Resident #51's shower sheet but stated she informed Resident #51's nurse. Interview on 10/28/24 at 3:53 P.M. with Licensed Practical Nurse (LPN) #212 confirmed she was the facility wound nurse and that she was notified on 10/24/24 that Resident #51 had an open area to her buttock. LPN #212 stated she completed a wound assessment on Resident #51, notified the physician and received new treatment orders. Interview on 10/29/24 at 7:35 A.M. with Licensed Practical Nurse (LPN) #203 confirmed she was the nurse who took care of Resident #51 on 10/24/24. LPN #203 stated she was aware Resident #51 had an 365616 Page 3 of 8 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0686 Level of Harm - Minimal harm or potential for actual harm open area on her buttock and was not sure how long Resident #51 had the area but stated she thought the area was new. LPN #203 stated she was notified in report the morning of 10/24/24 from night shift that Resident #51 had an area to her buttock. LPN #204 stated the wound nurse was notified on 10/24/24 and evaluated Resident #51's open area. LPN #203 confirmed Resident #51 was sent out to the hospital on [DATE] for altered mental status prior to new treatment orders getting entered into the computer system. Residents Affected - Few Review of the facility policy titled, Preventive Skin/wound care, revised 11/20/23, stated the facility was to assess residents for the potential risk of the development skin breakdown and residents with skin breakdown would be managed. The policy stated the physician/Nurse Practitioner would be notified of changes in skin and treatment orders obtained. This deficiency represents non-compliance investigated under Complaint Numbers OH00159184 and OH00158773. 365616 Page 4 of 8 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

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. Based on medical record reviews, staff interviews, observations and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#04 and #14) out of the four residents reviewed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record for Resident #04 revealed an admission date of 02/07/24 with medical diagnoses of atherosclerosis of native arteries, peripheral vascular disease, left hemiplegia, and adult failure to thrive. Review of the medical record for Resident #04 revealed a significant change Minimum Data Set (MDS) assessment, dated 07/27/24, which indicated was cognitively intact and required partial/moderate staff assistance with bed mobility, was dependent upon staff for toilet hygiene and transfers, and required substantial/maximum staff assistance for bathing. Review of the medical record for Resident #04 revealed a physician order dated 06/25/24 for metoprolol 25 milligram (mg) one tablet by mouth two times per day. The order also stated to hold the medication if systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. Review of the medical record for Resident #04 revealed the October 2024 Medication Administration record (MAR) which indicated Resident #04 received the metoprolol 25 mg on 10/02/24, 10/03/24, 10/05/24, 10/09/24, and 10/28/24 but did not have documentation to support the facility obtained Resident #04's blood pressure prior to administration of the metoprolol. Further review of the MAR, revealed on 10/12/24 Resident #04's blood pressure was 104/42 and the facility administered the metoprolol 25 mg tablet. 2. Review of the medical record for Resident #14 revealed an admission date of 11/08/22 with medical diagnoses of Alzheimer's disease, hypertensive chronic kidney disease, psychosis, dorsalgia, and osteoporosis. Review of the medical record for Resident #14 revealed a quarterly MDS assessment, dated 09/14/24, which indicated Resident #14 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, supervision with bed mobility, and substantial/maximum staff assistance with bathing. Review of the medical record for Resident #14 revealed a physician order dated 12/22/23 for Lidocaine 4% topically to apply to lower back daily and an order dated 04/20/24 for Lidocaine 4% patch topically to apply to left shoulder in the morning and remove in the evening. Observation on 10/28/24 at 8:30 A.M. revealed Registered Nurse (RN) #204 administered medication to Resident #14. The observation revealed when RN #204 went to apply Resident #14's lidocaine patch to his left shoulder, a lidocaine patch dated 10/27/24 was still on his left shoulder. RN #204 removed the old patch and placed the new patch on Resident #14's shoulder. Interview on 10/28/24 at 8:35 A.M. with RN #204 confirmed Resident #14's had a lidocaine patch dated 10/27/24 on his left shoulder when she went to apply his lidocaine patch and confirmed the order 365616 Page 5 of 8 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0755 stated to remove the lidocaine patch to the shoulder every evening. Level of Harm - Minimal harm or potential for actual harm Interview on 10/29/24 at 10:22 A.M. with Regional Clinical Support #225 confirmed the medical record for Resident #04 did not contain documentation to support the facility obtained Resident #04's blood pressure prior to administrator of metoprolol as ordered on 10/02/24, 10/03/24, 10/05/24, 10/09/24, and 10/28/24. Regional Clinical Support #225 also confirmed the documentation revealed the facility administered the metoprolol on 10/12/24 and Resident #04's blood pressure was 104/42. Residents Affected - Few Review of the facility policy titled, Medication Administration, dated November 2021, stated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy also stated medications are to be administered in accordance with written orders by the prescriber. This deficiency represents non-compliance investigated under Complaint Number OH00158773. 365616 Page 6 of 8 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, staff interviews, observations, and review of facility policies, the facility failed to follow infection control procedures during wound care. This affected one (#04) out of the three reviewed for wound care. The facility also failed to follow infection control procedures during medication administration. This affected one (#24) out of the three residents observed for medication administration. The facility census was 87. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #04 revealed an admission date of 02/07/24 with medical diagnoses of atherosclerosis of native arteries, peripheral vascular disease, left hemiplegia, and adult failure to thrive. Review of the medical record for Resident #04 revealed a significant change Minimum Data Set (MDS) assessment, dated 07/27/24, which indicated was cognitively intact and required partial/moderate staff assistance with bed mobility, was dependent upon staff for toilet hygiene and transfers, and required substantial/maximum staff assistance for bathing. The MDS indicated Resident #04 was at risk for skin breakdown and a Stage III pressure ulcer was present upon admission with treatment in place. Review of the medical record for Resident #04 revealed a physician order dated 06/25/24 for Enhanced Barrier Precautions (EBP), an order dated 08/08/24 to cleanse open area to coccyx with normal saline, apply small amount of wound gel, collagen, and bordered foam every other daily and as needed, and an order dated 08/30/24 to cleanse rectal wound with normal saline, apply wound gel, alginate, and bordered foam every other day and as needed. Observation on 10/24/24 at 1:07 P.M. of Licensed Practical Nurse (LPN) #212 complete wound care on Resident #04 revealed LPN #212 washed her hands and applied gloves. LPN #212 removed the soiled dressing from Resident #04's coccyx and rectal wound, cleansed each area and completed treatments as ordered. LPN #212 was not observed to be wearing a gown during wound care nor did LPN #212 change gloves or wash hands after removal of the soiled dressings from the wounds, prior to completing the treatment, or prior to applying clean dressing to the wounds. Interview on 10/24/24 at 1:17 P.M. with LPN #212 confirmed Resident #04 was under EBP and she had not donned a gown during wound care. LPN #212 also confirmed she had not changed gloves or performed hand hygiene after she removed the soiled dressings from Resident #04's coccyx and rectal wounds or prior to cleansing the wounds and applying new dressings. 2. Review of the medical record for Resident #24 revealed an admission date of 09/27/24 with medical diagnoses of ankylosing hyperostosis of cervical region, hypertensive heart disease, anemia, and atrial fibrillation. Review of the medical record for Resident #24 revealed an annual MDS assessment, dated 10/02/24, which indicated Resident #24 was cognitively intact, was dependent upon staff for toileting hygiene, and required substantial/maximum staff assistance with bathing, bed mobility, and transfers Review of the medical record for Resident #24 revealed a physician order dated 09/26/24 for gabapentin 300 milligram (mg) two times per day by mouth. 365616 Page 7 of 8 365616 10/29/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0880 Level of Harm - Minimal harm or potential for actual harm Observation on 10/28/24 at 8:18 A.M. of LPN #210 prepare Resident #24's medications for morning medication pass revealed LPN #210 drop the gabapentin 300 mg tablet onto the medication cart, pick the gabapentin up with her bare hands, and place the gabapentin into Resident #24's medication cup along with all the other morning medications. LPN #212 was observed to administer the medications to Resident #24 including the gabapentin. Residents Affected - Few Interview on 10/28/24 at 8:21 A.M. with LPN #212 confirmed dropped Resident #24's gabapentin 300 mg tablet onto the medication cart, used her bare hand to pick the gabapentin tablet up and placed the gabapentin tablet into the medication cup. LPN #212 confirmed she administered the gabapentin to Resident #24 along with all his other morning medications. Review of the facility policy titled, Enhanced Barrier Precautions, revised 11/30/23, stated EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO). The policy stated EBP is to be used for wounds, indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator), and known infection or colonization with a novel or targeted MDRO when contact precautions do not apply. Review of the facility policy titled, Dressing Change (clean), revised 06/08/22 stated the purpose was to protect wound, prevent irritation, infection and spread of infection, and promote healing. The policy stated staff are to wash hands, apply gloves, and remove soiled dressing and discard in plastic bad and dispose of gloves, and wash hands. Apply new gloves and cleanse wound. Dispose of gloves, wash hands, and apply new gloves. Apply new glove and apply dressing as ordered. Review of the facility policy titled, Medication Administration, dated November 2021, stated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy stated prior to medication administration the person administering medications adheres to good hand hygiene which includes washing hand thoroughly before the beginning a medication pass, prior to handling any medications (gloves are to be worn if direct contact), after coming into direct contact with resident, before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and before and after administration of medications. This deficiency represents non-compliance investigated under Complaint Numbers OH00159184 and OH00158773. 365616 Page 8 of 8