Health inspection·September 20, 2023

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident and staff interview, observation, policy review, and review of a Centers for Medicare and Medicaid Services (CMS) memo, the facility failed to ensure activities were provided to meet the needs of the residents. This affected three (#38, #40, and #86) of three residents reviewed for activities. The census was 87. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 07/15/21. Resident #40's medical diagnoses included bipolar disorder, diabetes, non-Alzheimer's dementia, and psychotic disorder. Review of Resident #40's annual Minimum Data Set (MDS) assessment, dated 07/03/23, revealed Resident #40 was cognitively intact. Review of the activities care plan, dated 08/02/23, revealed Resident #40 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #40 to participate in activities. Review of Resident #40's Record of One on One Activities, dated September 2023, revealed Resident #40 was documented as having a active reaction/response to a one on one activity of social chat on 09/01/23, a active reaction/response to a one on one activity of talking on 09/08/23 and 09/12/23. On 09/06/23, social was documented as Resident #38's one on one activity however Resident #38's reaction/response was documented as not in the room. Resident #38 had no additional one on one activities documented on the Record of One on One Activities form for September 2023. Review of Resident #40's Activity Participation for 09/01/23 through 09/14/23 revealed Resident #40 was documented as participating in book reading everyday between 09/01/23 and 09/14/23, TV in room everyday between 09/01/23 and 09/14/23, socializing with peers everyday between 09/01/23 and 09/14/23, outside everyday between 09/01/23 and 09/14/23, crossword/word search everyday between 09/01/23 and 09/14/23. Resident #40 was documented as participating in food related groups on 09/03/23, 09/04/23, and 09/06/23. Resident #40 was documented as participating in arts and crafts on 09/06/23, 09/07/23, 09/11/23, 09/13/23, and 09/14/23. Interview with Resident #40 on 09/13/23 at 10:04 A.M. revealed there had not been any structured activities in the past one to two weeks due to COVID-19. 2. Review of the medical record for Resident #38 revealed an admission date of 03/04/23. Resident #38's medical diagnosis included congested heart failure. Page 1 of 3 365644 365644 09/20/2023 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0679 Review of the quarterly MDS assessment, dated 07/21/23, revealed Resident #38 was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Review of Resident #38's activities care plan, dated 02/17/23, revealed Resident #38 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #38 to participate in activities. Residents Affected - Few Review of Resident #38's Record of One on One Activities, dated September 2023, revealed Resident #38 was documented as having a active reaction/response to a one on one activity of current events chat on 09/01/23, a active reaction/response to a one on one activity of talking on 09/08/23, 09/12/23, and 09/15/23. On 09/06/23, social/talk was documented as Resident #38's one on one activity however Resident #38's reaction/response was documented as not in the room. Resident #38 had no additional one on one activities documented on the Record of One on One Activities form for September 2023. Review of Resident #38's Activity Participation for 09/01/23 through 09/14/23 revealed Resident #38 was documented as participating in puzzles/cards everyday between 09/01/23 and 09/14/23, TV in room everyday between 09/01/23 and 09/14/23, socializing with peers everyday between 09/01/23 and 09/14/23, outside smoking everyday between 09/01/23 and 09/14/23, crossword/word search everyday between 09/01/23 and 09/07/23, trivia/reminiscing everyday between 09/01/23 and 09/14/23. Resident #38 was documented as participating in food related groups on 09/03/23, 09/04/23, and 09/06/23. Resident #38 was documented as participating in arts and crafts on 09/01/23, 09/04/23, 09/06/23, 09/07/23, 09/11/23, 09/13/23, and 09/14/23. Interview with Resident #38 on 09/19/23 at 10:38 A.M. revealed she was told there wasn't going to be any communal activities due to the COVID-19 virus. 3. Review of the medical record for Resident #86 revealed an admission date of 09/07/23. Resident #86's medical diagnosis included unspecified fracture of the left femur. Review of the progress note dated 09/07/23 revealed Resident #86 was alert and oriented times four. Review of the care plan dated 09/11/23 revealed Resident #86 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #86 to participate in group activities. Review of Resident #86's Record of One on One Activities, dated September 2023, revealed Resident #86 was documented as having a active reaction/response to a one on one activity of talk/nails on 09/12/23. Resident #86 had no additional one on one activities documented on the Record of One on One Activities form for September 2023. Review of Resident #86's Activity Participation for 09/08/23 through 09/14/23 revealed Resident #86 was documented as participating in trivia/reminiscing everyday between 09/08/23 and 09/14/23, TV in room everyday between 09/08/23 and 09/14/23, outside smoking everyday between 09/08/23 and 09/14/23, and arts and crafts everyday between 09/10/23 and 09/14/23. Interview with Resident #86 on 09/13/23 at 3:01 P.M. revealed there had not been any structured activities due to the facilities COVID-19 outbreak. 365644 Page 2 of 3 365644 09/20/2023 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility timeline for the COVID-19 outbreak revealed the first resident was found to be positive for COVID-19 on 08/23/23 and no new residents had tested positive for COVID-19 after 09/03/23. As of 09/13/23, all COVID-19 positive residents were removed from isolation. Review of the activity calendar for 09/13/23 revealed fall crafts was scheduled for 10:30 A.M., Optum shopping and a hydration cart/music was scheduled for 12:00 P.M., and national chocolate day was scheduled for 2:00 P.M. Observation on 09/13/23 from 10:25 A.M. to 10:34 A.M. revealed no evidence of the fall crafts activity having been completed as scheduled on the activity calendar. Resident #38, Resident #40, and Resident #86 were not observed participating in a structured group or individual activity. Observation on 09/13/23 at 12:00 P.M., revealed no evidence of the Optum shopping activity having been completed as scheduled on the activity calendar. Resident #38, Resident #40, and Resident #86 were not observed participating in a structured group or individual activity. Observation on 09/13/23 at 2:00 P.M. revealed no evidence of a National Chocolate Day activity having been completed as scheduled on the activity calendar. Resident #38, Resident #40, and Resident #86 were not observed participating in a structured group or individual activity. Interview with State Tested Nursing Aide (STNA) #121 on 09/13/23 at 9:30 A.M. revealed there weren't any communal activities for the residents since the most recent COVID-19 outbreak began. Interview with STNA #109 on 09/13/23 at 9:45 A.M. revealed there had not been any communal activities for the residents since the most recent COVID-19 outbreak started. Interview with Activity Director (AD) #180 on 09/13/23 at 2:25 P.M. revealed she revised the schedule for the activities due to COVID-19 and was not conducting communal activities for the residents. Interview with Receptionist #192 on 09/19/23 at 10:33 A.M. revealed there had not been any communal activities since the most recent COVID-19 outbreak began. Review of the policy titled Activity Program, undated, revealed the facility would provide activity programs that are designed to meet the needs of residents and are available on a daily basis. Various activities are provided to meet the needs of residents with a range of cognitive and physical levels of functioning. The policy further revealed social distancing and isolating/sheltering in place does not mean that the fun must stop! In fact, the energy level of activity staff must increase. Review of the CMS memo QSO-20-39-NH, revised 05/08/23, revealed while adhering to the core principles of COVID-19 infection prevention, communal activities may occur. This deficiency represents non-compliance investigated under Master Complaint Number OH00146252. 365644 Page 3 of 3