Health inspection·March 16, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure residents needs were met by answering call lights in a timely manner. This affected two (#124 and #126) of two residents reviewed for call lights. The facility census was 78. Residents Affected - Few Findings included: 1. Medical record review for Resident #124 revealed an admission date of 03/0723, with diagnoses including stroke and arthritis. Review of 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #124 was cognitively intact. Her functional status was limited assistance for bed mobility and transfers. She was a supervision for eating and extensive assistance for toilet use. She was always continent for bowel and bladder. Observation on 03/13/23 at 1:49 P.M., revealed Resident #124 was in bed and pulled her call light because she had to go to the bathroom. At 1:54 P.M., Hospitality Aide (HA) #419 came into the room and asked what Resident #124 needed and Resident #124 stated she had to go to the bathroom. HA #419 stated someone would be with her shortly and turned off the call light. At 2:22 P.M., Resident #124 again turned on the call light and at 2:29 P.M., Resident #124 was finally assisted to the bathroom. Interview on 03/13/23 at 3:05 P.M., with State Tested Nursing Aide (STNA) #464 revealed HA #419 did tell her Resident #124 had to go to the bathroom, but she was busy doing a bed bath. STNA #464 stated she told HA #419 to let another STNA #463, know to help Resident #124, but she was doing a bed bath too. STNA #464 stated the expectation for answering a call light would be less than seven minutes. STNA #464 stated she didn't ask the nurse to help her with the call lights, because they were busy and doesn't expect them to drop what they are doing to help her with a call light. 2. Medical record review for Resident #126 revealed an admission date of 03/10/23, with diagnoses including metabolic encephalopathy, and chronic obstructive pulmonary disease (COPD) Review of admission MDS assessment dated [DATE] revealed Resident #126 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. She was supervision for eating. Observation on 03/13/23 at 2:07 P.M., revealed Resident #126 pulled her call light because she had to go to the bathroom. STNA #465 came into the room and turned off the call light and told Resident #126, she would have to wait to go to the bathroom since STNA #463 was busy with another resident. Page 1 of 17 365743 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 2:15 P.M., Resident #126 could be heard yelling in the hall saying help and STNA #465 went into her room Resident #126 was stating she had to go to the bathroom and STNA #465 stated, you have to wait because the other aide was busy with another resident and I promise I will be back. At the time of observation, the RN #429 was seen standing at the nursing station and the aide did not ask for help. At 2:21 P.M., a housekeeper goes into the room and the resident asks her to take her to the bathroom and the housekeeper stated I can't get you up, but they will be here soon. At 2:24 P.M., both aides come to help the resident up to the bathroom. Interview on 03/13/23 at 2:45 P.M., with STNA #465 revealed she had to wait for the other aide to help her get Resident #126 up to the bathroom. STNA #465 confirmed she didn't want to ask the nurse who was standing at the nursing station because she was busy. STNA #465 stated she likes to answer the call lights in less than seven minutes. Interview on 03/13/23 at 3:00 P.M.,with Resident #126 revealed the staff are not timely in answering the call light and she had to go to the bathroom urgently. Resident #126 stated she felt angry when the staff wouldn't answer the call light in a timely manner. Resident #126 stated she didn't want to be in the facility anymore. Review of undated policy titled Call Light revealed the purpose of the call light was to respond to the resident's requests and needs. When you answer the call light make sure you do what the resident asks of you if permitted and you cannot fulfill the request, ask the nurse supervisor for help. 365743 Page 2 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policy review, the facility failed to honor a resident's choice and physician order related to advance directives. This affected one (#73) of three residents reviewed for advance directives. The facility census was 78. Findings include: Record review for Resident #73 revealed she was admitted to the facility on [DATE], and died at the facility on [DATE]. Her diagnoses included diabetes mellitus 2, hypoglycemia, cardiac murmur, altered mental status, essential primary hypertension, Alzheimer's Disease, and dysphagia. Review of Resident #73's care plan for code status, dated [DATE], revealed she was a full code. An intervention was listed as, periodically review advance directives with the resident/family, initiated [DATE]. Review of physician visit dated [DATE], for Resident #73 revealed the physician reviewed advanced directives during the visit. Implication of new code status reviewed with patient/representative and understanding was verbalized. Code status has been updated to DNRCC-A (do not resuscitate comfort care-arrest). Review of the physician orders for Resident #73 revealed an order for an Advance Directive change, dated [DATE], Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Review of Resident #73's Advance Directive Form titled, DNR Comfort Care, dated [DATE], revealed a physician signed the form for Resident #73 stating she was a DNRCC-Arrest. Review of the progress notes dated [DATE] at 9:55 A.M., for Resident #73, revealed Resident #73 was found with no vital signs. No signed DNR in facility or on file, 911 called and Cardiopulmonary Resuscitation (CPR) initiated at 10:00 A.M. Resident was pronounced deceased at 10:32 A.M. by Paramedic. Interview on [DATE] at 10:47 A.M., with Licensed Practical Nurse (LPN) #420 confirmed she was the nurse working on [DATE] when Resident #73 was found with no vital signs. LPN #420 stated the staff was unable to locate DNRCCA form for Resident #73. LPN #420 stated she was on the phone with the Director of Nursing (DON) and was advised to call a full code and start CPR. LPN #420 reviewed and confirmed the Advance Directive form for Resident #73 stated Resident #73's code status was marked DNRCC-A and signed by the physician on [DATE]. LPN #420 stated she was not sure where that form was located on the morning of Resident #73's death. Review of the policy titled, Advanced Directive, dated [DATE], revealed it is the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. Any decision making will be documented in the resident's medical record and communicated to the interdisciplinary team. 365743 Page 3 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0610 Respond appropriately to all alleged violations. 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 interviews, and policy review, the facility failed to complete an investigation related to potential misappropriation of a resident's personal belongings. This affected one (#46) of three residents reviewed for potential misappropriation. The facility census was 78. Residents Affected - Few Findings include: Record review for Resident #46 revealed she was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus 2, cellulitis, benign neoplasm of colon, gastro-esophageal reflux disease, chronic kidney disease, pneumonia, osteomyelitis, and insomnia. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/23, revealed Resident #46 was cognitively intact. Further review of the MDS assessment revealed Resident #46 required extensive assistance from staff with transfers, dressing, toilet use, and personal hygiene. Resident #46 required limited assistance from staff with eating. Interview on 03/13/23 at 11:34 A.M., with Resident #46 revealed the resident reported missing items including several pairs of pants and tops missing from the date of her admission on [DATE]. Resident #46 stated she reported the missing personal items to Social Worker (SW) #417 and nothing has been done regarding the missing items. Resident #46 stated she was not aware of the need to write her name in her clothing until she brought in additional clothing in and believes that is why her clothing is missing. Interview on 03/15/23 at 5:09 P.M., with Social Worker (SW) #417 confirmed Resident #46 told her about the missing items in January of 2023. SW #417 stated Resident #46 told her she was missing a top and several pairs of capris pants. SW #417 stated she told laundry about Resident #46's missing clothing, however, forgot to follow up on the missing items. SW #417 stated Resident #46 did not write her name on the tags of her clothing and this is why Resident #46's clothing is missing. SW #417 stated the facility identified an issue with new admission resident's clothing not getting marked and debated on who will complete the task. SW #417 believed the facility was going to assign State Tested Nurse Aides (STNA) to mark new admission resident clothing, however, she is not sure. SW #417 confirmed the facility failed to complete an investigation regarding Resident #46's missing clothing. Review of the facility policy titled, Abuse Investigating and Reporting, dated September 2021, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to locale, state, and federal agencies and thoroughly investigated by facility management. 365743 Page 4 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interview, the facility failed to ensure residents were screened for Preadmission Screening and Resident Review (PASARR) services upon admission and after new diagnoses for serious mental illness. This affected two(#36 and #59) of two residents reviewed for PASARR. The facility census was 78. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #36 admitted to the facility on [DATE], diagnoses that included chronic obstructive pulmonary disease, acute on chronic combined congestive heart failure, morbid obesity, type II diabetes, unspecified dementia, unspecified bipolar disorder, unspecified anxiety disorder, unspecified major depressive disorder and paranoid schizophrenia ([DATE]). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 36 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #36 was a two-person assist, required supervision with eating, and required extensive assistance with all other Activities of Daily Living (ADL's). Review of the medical record revealed Resident #36 had no evidence of a PASARR screening being completed upon admission and no significant change PASARR completed after new diagnosis of paranoid schizophrenia added on [DATE]. Interview on [DATE] at 9:38 A.M. , with Social Worker (SW) #417 verified there was no documentation in the medical record of completed PASARR for admission or after the new diagnosis was added. Interview on [DATE] at 12:02 P.M., Regional Executive Director #460 stated the facility did not have a PASARR policy. They completed PASARR upon admission and for significant change. 2. Review of the medical record revealed Resident #59 admitted to the facility on [DATE] and had diagnoses that included chronic obstructive pulmonary disease, type II diabetes, moderate vascular dementia with behavioral disturbance, acute on chronic congestive heart failure, and generalized anxiety disorder. Review of the most recent Minimum Data Set, dated [DATE] revealed Resident #59 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident # 59 was a two-person assist and required extensive assistance with all ADL's. Review of the medical record revealed Resident #56 had a Hospital Exemption and Preadmission Screening Notification dated [DATE] from a previous admission and stay at the facility. There was no additional PASARR information available in the medical record dated after the resident readmitted to the facility on [DATE]. Interview on [DATE] at 9:39 A.M. , with SW #417 stated she reviewed Resident #59's record and did not find any documentation for PASARR. SW #417 stated usually residents come from hospital with PASARR and she reviewed, or completed a new PASARR after 30-day hospital exemption PASARR expired. SW #417 verified Resident #56 had admitted from the hospital on [DATE] with a hospital exemption PASARR that expired in [DATE], and stated she should have filled out a new PASARR in [DATE]. 365743 Page 5 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, the facility failed to develop a care plan to meet a resident's dental needs. This affected one (#41) of 24 residents reviewed for care plans. The facility census was 76. Findings included: Review of the medical record for Resident #41 revealed an admission date of 06/23/21, with diagnoses that included cerebral infarction due to unspecified stenosis of the right middle cerebral artery, chronic obstructive pulmonary disease, unspecified protein calorie malnutrition, unspecified chronic kidney disease, and unspecified major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact, had no behaviors, did not wander and did not reject care. Resident #41 was a one-person assist. Resident #41 required extensive assistance with bed mobility and supervision with all other Activities of Daily Living (ADL's). Review of the care plans dated 06/06/22 revealed Resident #41 had no care plan specific to care or missing/broken teeth or dental care. Review of Care 360 documentation dated 06/10/22 revealed Resident # 41 had partial dentition and recommendations for treatment included extraction/forceps removal of teeth #5, #6, #7, #8, #9, #10, #11, #18, #20, #21, #22, #27, #28, #29, and #32. Additional review revealed Care 360 physician completed a referral for oral surgery for extraction of the teeth. Review of Care 360 documentation dated 10/10/22 revealed Resident # 41 was seen by dental hygienist for preventative care and the resident stated she wanted all of her teeth removed and a full set of dentures. Observation and interview on 03/13/23 at 10:02 A.M., revealed Resident #41 had multiple missing, broken, and discolored teeth. Resident #41 stated the dentist was supposed to be at the facility on the 15 th, and she needed teeth pulled so she could get full dentures. Resident #41 stated she had requested her teeth be pulled several times (dates not specified) and nothing had been done. Interview on 03/16/23 at 10:00 A.M., with the Director of Nursing (DON) verified Resident #41 had no care plan for dental care prior to 03/15/23. 365743 Page 6 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and policy review, the facility failed to hold timely care conferences. This affected two (#21 and #36) of 24 residents reviewed for care conferences. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident # 21 admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, unspecified vascular dementia, and unspecified anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #21 was a one person assist, required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, and supervision assistance with eating and locomotion. Review of the medical record revealed Resident #21 had documentation for care conferences dated 10/28/21, 10/24/22, and 11/04/22. Interview on 03/13/23 at 10:58 A.M., with Resident #21 stated she did not receive regular care conferences. Interview on 03/15/23 at 9:36 A.M., with Social Worker (SW) #417 stated care conferences were supposed to be quarterly. SW #417 stated she started her position with the facility in May 2022 and did not start holding care conferences until October 2022. 2. Review of the medical record revealed Resident #36 admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, acute on chronic combined congestive heart failure, morbid obesity, type II diabetes, unspecified dementia, unspecified bipolar disorder, unspecified anxiety disorder, unspecified major depressive disorder, and paranoid schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #36 was a two-person assist, required supervision with eating, and required extensive assistance with all other Activities Daily of Living (ADL's). Review of the medical record revealed Resident #36 had no record of quarterly care conferences held in 2022. Interview on 03/13/23 at 11:13 A.M., with Resident #36 stated she has never had a care conference at the facility. Interview on 03/15/23 at 9:32 A.M., SW #417 stated Resident #41 asked for a care conference and asked for her sister to be present back in November 2022. SW #417 stated she tried to reach Resident #41's sister, left her a message, and she never received a return call. SW #417 confirmed she did not 365743 Page 7 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have any care conferences with Resident #41 and stated she should have gone ahead and had the care conference without her sister. SW #417 stated care conferences were supposed to be held quarterly. SW #417 stated she had been in this position since May 2022 but her training was only for admissions and discharges. She did not really get started scheduling care conferences for residents until October 2022. Review of policy titled Care Conference dated 09/01/21 revealed the facility held regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the Plan of Care. 365743 Page 8 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure treatments were completed as ordered and obtain orders for a treatment. In addition, the facility failed to clean scissors prior to use and perform hand hygiene during wound care. This affected two (#6 and #46) of six residents reviewed for wound treatments. The facility census was 78. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #6 admitted to the facility on [DATE], with diagnoses that included unspecified interstitial pulmonary disease, type II diabetes, acute on chronic combined congestive heart failure, and unspecified stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 6 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #6 had physician orders dated 03/05/23, to cleanse right wrist skin tear with normal saline/pat dry/cover with band aid daily until resolved. There was no physician order for a dressing to the right elbow. Observation on 03/14/23 at 11:31 A.M., revealed Resident #6 wore a hospital gown and was seated on the edge of her bed. Resident #6 had a bordered gauze dressing on her right elbow dated and labeled 03/12/23 SEP 1600 and band-aid on her right wrist dated 03/12/23. The bordered gauze to the right elbow was peeling at the edges and had a nickel-sized area of dark brownish-red drainage. Observation and interview on 03/14/23 at 11:35 A.M., with Licensed Practical Nurse (LPN) #404 looked at dressing on right elbow right wrist, verified both bandages were dated 03/12/23. LPN #404 stated both dressings were supposed to be changed daily. 2. Review of the medical record revealed Resident #46 admitted to the facility on [DATE], with diagnoses that included type II diabetes, unspecified cellulitis, unspecified myelitis, stage III chronic kidney disease, and unspecified osteomyelitis. Review of MDS assessment dated [DATE] revealed Resident #46 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #46 was a one-person assist was totally dependent for locomotion, required supervision for eating, and required extensive assistance with all remaining Activities of Daily Living (ADL's). Review of the medical record revealed Resident #46 had physician orders dated 03/15/23 for wound care to cleanse right hip with normal saline, pat dry, apply silvasorb gel to wound bed, cover with calcium alginate, and cover with foam dressing every day shift for skin integrity. Observation on 03/16/23 at 1:36 P.M., revealed LPN #404 gathered supplies from treatment cart including normal saline, calcium alginate, Silvasorb gel, sterile gauze pads, and bordered foam dressing and carried the supplies to Resident #46's room. LPN #404 assessed Resident #46 for pain, donned gloves without washing her hands, and removed the old dressing from Resident #46's right hip. The area appeared to be a half-dollar sized round, raised, and reddened skin with a smaller dime-sized open area in the center with scant yellow exudate. LPN #404 did not remove her gloves, wash her hands, or 365743 Page 9 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few don clean gloves before she opened sterile gauze, squirted normal saline from an ampoule onto the gauze, cleansed wound, patted wound dry with fresh gauze, removed bandage scissors from her pants pocket, and cut a dime-sized piece of calcium alginate. LPN #404 did not disinfect her scissors before she placed her scissors back in her pocket. LPN #404 did not doff gloves, wash hands, or don clean gloves before she squeezed pea sized amount of Silvasorb gel onto the finger of her soiled gloves and placed with the medication on the wound bed, placed calcium alginate over the wound gel, and covered the wound with bordered gauze. LPN #404 doffed her gloves and changed trash liner, washed her hands in bathroom sink, carried the trash to soiled utility, and sanitized her hands. Interview on 03/16/23 at 1:50 P.M., with LPN #404 verified she did not wash her hands before initiating Resident #46's wound care treatment and did not change her gloves or wash her hands between removing the soiled dressing and applying the new dressing. The LPN verified she used the bandage scissors from her pocket and did not disinfect her scissors before using them during the dressing change. Review of the policy titled Wound Care dated September 2021, revealed nurses provided wound care according to physician orders and were expected to wash and dry hands thoroughly and don gloves before initiating wound care, after removing a dressing, and after cleaning a wound and applying treatments. 365743 Page 10 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

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 interview and policy review, the facility to ensure wounds were assessed and staged timely and failed ot ensure pressure relieving devices were in place to prevent skin impairments. This affected two (#34 and #11) of five reviewed for pressure ulcers. The facility identified there were five pressure ulcers in the facility. The facility census was 78. Residents Affected - Few Findings included: 1. Medical record review for Resident #34 revealed an admission of 09/07/22, with diagnoses that included other neurological conditions, heart failure, renal insufficiency, urinary tract infection, diabetes, hemiplegia and hemiparesis, cerebrovascular attack (CVA), anxiety, and depression. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 revealed was cognitively intact, with functional status of extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Resident #34 eating was supervision and was frequently incontinent for bowel and bladder. Review of care plan dated 02/17/23 for Resident #34 revealed to place Prevalon Boots (pressure relieving boots) as tolerated. Review of progress notes dated 03/11/23 revealed Resident #34 admitted back from the hospital and a skin assessment was completed upon admission. Review of the skin assessment dated [DATE] for Resident #34 revealed the resident had skin impairments and it was pressure with no description. Review of progress note dated 03/13/23 revealed Resident #34 had a second skin check and was admitted with a coccyx stage two pressure area with no description. Observation on 03/14/23 at 11:43 A.M., 2:17 P.M., 3:22 P.M. and on 03/15/23 at 2:00 P.M., revealed Resident #34 didn't have his boots on and they were on the top shelf of his closet. Interview on 03/15/23 at 2:15 P.M., with the Resident #34 revealed his boots had not been on him since he was admitted and denied he had refused to wear them. Interview on 03/15/23 at 2:20 P.M., with the Assistant Director of Nursing (ADON) confirmed Resident #34 didn't have his boots on and they were in the closet. Interview on 03/16/23 at 7:28 A.M., with the Director of Nursing (DON) confirmed there wasn't description of the wound for Resident #34 on 03/11/23 and stated this was the way the facility was checking skin was to check mark yes. Resident #34 had a skin impairment and check mark it was pressure but to not describe the wound. The second nurse would come behind the first nurse and describe the wound and stage it in this case two days later. She stated this was per corporate nurse, but they were thinking about putting the grid for descriptions on the form. 2. Medical record review for Resident #11 revealed an admission of 04/29/22, with diagnoses that included unspecified protein-calorie malnutrition, chronic respiratory failure, with hypoxemia, 365743 Page 11 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dysphagia, muscle weakness, unsteadiness on feet, muscle wasting and atrophy, unspecified dementia, unspecified severity with agitation, chronic kidney disease stage 4, atherosclerotic heart disease of native coronary artery,angina pectoris, atrial fibrillation, acute on chronic diastolic congestive heart failure. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Her functional status was extensive assistance for bed mobility, transfers, wheelchair bound currently, and toilet use with two-person assistance, frequently incontinent of bowel and bladder. She was set up and supervision for eating, very pleasant mood with poor safety awareness and periods of extreme agitation with some aggression. Review of the skin assessment dated [DATE] for Resident #11 revealed no new skin issues at the time of assessment. No skin issues documented at the time of assessment. Review of progress notes dated 11/24/22 revealed Resident #11 was out with family and upon return to the facility, a wound on the foot was found and documented by LPN #490 as an unstageable pressure ulcer then changed to a Stage 3 pressure ulcer by LPN #490. The wound was described to have necrotic tissue. Review of progress note dated 11/30/22, revealed Resident #11 had a skin check and by the Wound Nurse Practitioner (WNP) #1 and a treatment was started. The wound described by WNP #1 on initial wound encounter was: measurements- 1 centimeter (cm) length x 1.8 cm width x 0.3 cm depth, with an area of 1.8 square centimeter (sqcm) and a volume of 0.54 Cubic cm. wound had a moderate amount of serosanguineous drainage noted with no odor, wound bed had 1-25%slough, 76% -100% bright red granulation. the periwound skin exhibited maceration, temperature of the periwound was with in normal limits (WNL). The wound did not exhibit signs or symptoms of infection. Interview on 03/16/23 at 10:02 A.M., with Resident #11's daughter concerning pressure wound on Resident #11, stated the wound was the size of silver dollar, the whole skin was separated from her foot but still attached (skin flap), very white and dangling, seemed like a callus had fallen off, no bleeding seen or noted. Interview on 03/16/23 at 10:07 A.M., with WNP #1 revealed a wound from a blister or from deep tissue injury, opened up from hitting it during family outing on 11/24/22, and assessed by WNP #1 on 11/30/22. Granulated tissue, mostly healthy wound, with some slough, very good closure. WNP #1 stated the nurse had called it a unstageable/stage 3 upon initial observation. Interview on 03/16/23 at 8:28 A.M., with the Director of Nursing (DON) confirmed there wasn't an accurate assessment and description of the wound for Resident #11 on 11/24/22 and stated the facility was documenting skin assessments and wounds on the forms. Resident #11 had a skin impairment and it was marked as pressure but an accurate description of the wound was not documented. She stated this was per corporate nurse, but they were thinking about putting the grid for descriptions on the form. Review of the undated policy titled Pressure Ulcers revealed the nursing staff will describe the pressure ulcer including the location, stage, length, width, and depth presence of exudate, or necrotic tissue, tunneling and undermining 365743 Page 12 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

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. Based on medical record review, observations, and staff interviews, the facility failed to implement fall prevention interventions for a resident. This affected one (#286) of one resident reviewed for accidents. The facility census was 78. Findings include: Record review for Resident #286 revealed an admission date of 12/27/22, with diagnoses that included cerebral infarction, anxiety, vascular dementia, polyarthritis, essential primary hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/17/23 revealed Resident #286 had impaired cognition. Further review of the MDS assessment revealed Resident #286 required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene and required limited assistance from staff with eating. Review of the fall care plan for Resident #286 revealed, dycem to wheelchair, dated 03/15/23. Further review of the fall care plan for Resident #286 mat on floor next to floor next to bed when occupied, dated 12/28/22. Review of the fall report for Resident #286, dated 03/06/23 revealed the fall intervention added was, dycem to wheelchair. Observation on 03/15/23 at 8:25 A.M., revealed Resident #286's wheelchair was located next to Resident #286's bed and did not have dycem in it or anywhere in the room. Interview on 03/15/23 at 8:35 A.M., with with State Tested Nurse Aide (STNA) #402 confirmed Resident #286 did not have dycem in her wheelchair. STNA #402 confirmed she should have dycem in the wheelchair and Resident #286 did not have any located in her wheelchair or in her room. Interview on 03/15/23 at 08:36 A.M., with Licensed Practical Nurse (LPN) #480 confirmed the facility failed to add dycem to the wheelchair to Resident # 286's current fall care plan. Observation on 03/13/23 at 10:15 A.M., revealed Resident #286 was lying in bed and did not have a fall mat located bedside the bed. Observation on 03/14/23 at 5:28 P.M., revealed Resident #286 was lying in bed and did not have a fall mat located beside her bed. Interview on 03/14/23 at 5:28 P.M., with Registered Nurse (RN) #457 confirmed Resident #286 did not have a fall mat located next to her bed. RN #457 confirmed #286 should have a fall mat located next to her bed as a fall risk intervention. 365743 Page 13 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to provide care and treatment for incontinence care and ensure hand washing was completed post care. This affected one (#34) of one resident reviewed for incontinence care. The facility identified there was 51 incontinent residents. The facility census was 78. Findings included: Medical record review for Resident #34 revealed an admission of 09/07/22, with diagnoses that included other neurological conditions, heart failure, renal insufficiency, urinary tract infection, diabetes, hemiplegia and hemiparesis, cerebrovascular attack (CVA), anxiety, and depression. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 revealed was cognitively intact, with functional status of extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Resident #34 eating was supervision and was frequently incontinent for bowel and bladder. Observation on 03/15/23 at 9:54 A.M., revealed the State Tested Nursing (STNA) #485 turned the resident to provide care to the bottom and the resident had a bowel movement. She removed a bandage from a pressure ulcer. She took a washcloth that didn't have any soap on it. STNA #485 wiped the resident with it to remove the feces and turned him over and placed a brief on him. The sheet was wet with water that was spilled on it and the aide left the sheet wet and placed a new draw sheet on top of the wet sheet. The aide completed the task and removed her gloves and went out to the hall without washing her hands. Interview on 03/15/23 at 9:54 A.M., with the State Tested Nursing Aide (STNA) #485 confirmed she didn't use a soapy cloth on the resident's bottom, rinse with a clean cloth and dry with a dry cloth. She also confirmed she didn't change the sheet and didn't wash her hands and admitted she should have. Review of the undated policy titled Perineal Care revealed after cleansing the urethral area to clean the resident, wet a washcloth, apply soap or skin cleansing agent, wash and rinse the rectal area, and dry thoroughly. Discard the disposable items into designated containers and remove the gloves and wash and dry hands thoroughly. 365743 Page 14 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure a resident received required dental services to meet the residents dental needs. This affected one (#41) of two residents reviewed for dental care. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #41 revealed an admission date of 06/23/21, with diagnoses that included cerebral infarction due to unspecified stenosis of the right middle cerebral artery, chronic obstructive pulmonary disease, unspecified protein calorie malnutrition, unspecified chronic kidney disease, and unspecified major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact, had no behaviors, did not wander and did not reject care. Resident #41 was a one-person assist. Resident #41 required extensive assistance with bed mobility and supervision with all other Activities of Daily Living (ADL's). Review of the care plans dated 06/06/22 revealed Resident #41 had no care plan specific to care or missing/broken teeth or dental care. Review of Care 360 documentation dated 06/10/22 revealed Resident # 41 had partial dentition and recommendations for treatment included extraction/forceps removal of teeth #5, #6, #7, #8, #9, #10, #11, #18, #20, #21, #22, #27, #28, #29, and #32. Additional review revealed Care 360 physician completed a referral for oral surgery for extraction of the teeth. Review of Care 360 documentation dated 10/10/22 revealed Resident # 41 was seen by dental hygienist for preventative care and the resident stated she wanted all of her teeth removed and a full set of dentures. Observation and interview on 03/13/23 at 10:02 A.M., revealed Resident #41 had multiple missing, broken, and discolored teeth. Resident #41 stated the dentist was supposed to be at the facility on the 15 th, and she needed teeth pulled so she could get full dentures. Resident #41 stated she had requested her teeth be pulled several times (dates not specified) and nothing had been done. Interview on 03/15/23 at 9:18 A.M., with Social Worker (SW) #417 stated she was at the facility in June 2022 and did not remember seeing a referral for Resident #41's multiple tooth extractions. SW #417 did not know if Resident #41 ever went out to see an oral surgeon regarding the referral. Interview on 03/15/23 at 2:13 P.M., via telephone, with Licensed Practical Nurse (LPN) #459 stated she worked two days per week on scheduling appointments, and she did not recall any dental referral for Resident #41 to have teeth pulled in June 2022. LPN #459 stated typically any referrals from 360 care would go to SW #417 first and referrals for appointments, if needed, were typically left on the desk, slid under her door, or told to her by word of mouth. Interview on 03/16/23 at 9:19 A.M., with the Director of Nursing (DON) verified Resident #41 had no follow up appointment after dental referral for multiple tooth extractions dated 06/10/22. 365743 Page 15 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, the facility failed to ensure residents meals do not include food identified as an allergy. This affected two (#21 and #42) of two residents reviewed for food allergies. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #21 admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, unspecified vascular dementia, and unspecified anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #21 was a one person assist, required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, and supervision assistance with eating and locomotion. Review of Resident #21's nutrition care plan, initiated 11/14/22, revealed Resident #21 has an allergy to strawberries and is lactose intolerant. Observation on 03/13/23 at 12:07 P.M., revealed Resident #21 received her meal tray. The meal tray contained strawberry ice cream. Resident #21 stated, I am allergic to strawberries. Interview on 03/13/23 at 12:07 P.M., with State Tested Nurse Aide (STNA) #441 confirmed Resident #21's meal ticket stated Resident #21 has an allergy to strawberries and is lactose intolerant. STNA #441 confirmed Resident #21 received strawberry ice cream on her lunch tray. 2. Review of the medical record revealed Resident #42 admitted to the facility on [DATE], with diagnoses that included unspecified osteomyelitis, type II diabetes, morbid obesity, chronic obstructive pulmonary disease, and unspecified epilepsy. Review of Minimum Data Set (MDS) assessment dated revealed Resident # 42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #42 was a two-person assist, required supervision assistance for eating, and required extensive assistance for all remaining ADL's. Review of Resident #42's diet care plan, initiated 12/24/23, revealed she is allergic to strawberries. Observation on 03/15/23 at 12:04 P.M., revealed Resident #42 received her lunch tray with a strawberry shake located on her lunch tray. Interview on 03/15/23 at 12:05 A.M., with the Activity Director (AD) #461 confirmed Resident #42 received a strawberry milkshake on her lunch tray. AD #461 confirmed Resident #42's meal ticket listed strawberries as a food allergy. 365743 Page 16 of 17 365743 03/16/2023 Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on record review and staff interview, the facility failed to provide specific and specialized training staff working on the Memory Care unit. This had to potential to affect 15 (#11, #22, #23, #30, #40, #44, #47, #48, #49, #52, #53, #54 ,#58, #324 #325) of 15 residents residing on the Memory Care unit. The facility census was 78. Findings include: Employee record review revealed State Tested Nurse Assistant (STNA) #433 was hired on 10/18/21. Further review of the employee file for STNA #433 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #479 was hired on 09/13/21. Further review of the employee file for STNA #479 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #487 was hired on 02/27/23. Further review of the employee file for STNA #487 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #493 was hired on 02/27/23 . Further review of the employee file for STNA #493 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Interview on 03/15/23 at 4:15 P.M., with the Business Office Manager (BOM) #451 manager confirmed the facility has a speciality unit known as the Memory Care Unit that specializes in cognitive impaired residents with dementia. BOM #451 confirmed the facility failed to provide training for the speciality unit for new employees. BOM #451 stated the facility will schedule new employees to work on the Memory Care Unit during orientation. However, BOM #451 was unable to provide any type of verification of the orientation hours. BOM#451 confirmed the facility does not provide any other type of training for the Memory Care unit. Review of the policy titled, Dementia Care, dated September 2021, revealed the facility is committed to providing the highest quality of life through providing excellent care to our residents diagnosed with dementia and present with dementia related behaviors while preserving their dignity and self-respect. · 365743 Page 17 of 17