Health inspection·July 22, 2021

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure the resident was invited to her care plan conference meetings to provide input to her plan of care. This affected one (#32) of three residents reviewed for participation in care planning. The facility census was 81. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, major depressive disorder, and gastro-esophageal reflux disease. The resident was her own responsible party. Review of the annual Minimum Data Set (MDS) assessment, dated 06/07/21, revealed the resident had no impaired cognition for decisions. Record review revealed Resident #32 has not been offered to attend care conference meeting within the past 12 months. Interview on 07/19/21 at 2:10 P.M. with Resident #32 reported not attending a care plan meeting once since she was admitted and nothing after that. Interview on 07/21/21 at 9:33 A.M. with Director of Social Services (DSS) #7 stated before COVID-19, the facility mailed out invitations at the end of the month. Invitations were documented in the interdisciplinary (IDT) meetings. DSS #7 reported care conferences were probably not documented. DSS #7 verified no documentation of Resident #32 being invited to care conferences and denied having any letters for care plan meetings for Resident #32. Interview on 07/21/21 at 2:30 P.M., the Director of Nursing (DON) verified care conference was held for Resident #24 on 09/07/20 but unable to verify Resident #32's invitation or participation. DON denied having any documentation of attendance sheet or a letter inviting Resident #32 to care plan meetings in the past year. DON referred surveyor back to DSS #7. Page 1 of 10 365786 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, review of the facility's policy, and resident and staff interviews, the facility failed to develop and implement care plans to address dental care, hospice care, and fluid restrictions. This affected five (#4, #8, #36, #42, and #46) of 19 residents reviewed for care planning. The facility census was 81. Findings include: 1. Medical record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, and personal history of coronavirus (COVID 19). Review of Resident #36's progress note, dated 04/06/21, revealed Resident #36 had seen the dentist briefly, but resident stated he was planning to discharge back to the community, and he wanted to see his own dentist. Review of Resident #36's annual Minimum Data Set (MDS) assessment, dated 06/09/21, revealed the resident was cognitively intact and required supervision with personal hygiene. Resident #36 was reported to have obvious or likely cavities or broken natural teeth. Review of Resident #36's care plan, dated 07/20/21, revealed the resident did not have a dental care plan. Interview with Resident #36 on 07/19/21 revealed he needed his top teeth pulled. Interview with Social Services (SS) #7 on 07/21/21 at 8:34 A.M. revealed Resident #36 refused dental services on 04/06/21 due to resident planning to discharge. Interview with the Director of Nursing (DON) on 07/22/21 at 8:26 A.M. verified Resident #36 did not have a dental care plan prior to 07/22/21. 2. Review of the medical record for the Resident #8 revealed an admission date of 08/13/18. Diagnoses included congestive heart failure (CHF), chronic kidney disease (CKD), and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/01/21, revealed the resident was cognitively intact. Review of the physician orders, dated 10/26/20, revealed Resident #8 had a fluid restriction of 2,000 milliliter (ml.) total in 24 hours every shift for CHF which included 1,080 ml. for dietary, and 920 ml. for nursing departments. Review of the care plan, dated 05/04/21, revealed Resident #8 had altered cardiovascular status hypertension, CHF, CKD, and anxiety. Resident #8 was on diuretic therapy related to hypertension and CHF. Interventions included to administer diuretics as ordered and monitor for side effects and effectiveness, and gradual dose changes as needed. Resident #8 had altered nutrition and hydration related to hypertension, chronic bronchitis, 365786 Page 2 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0656 Level of Harm - Minimal harm or potential for actual harm arthritis, emphysema, pneumonia, chronic respiratory failure, asthma, hypotension, history of significant weight changes. Family brought outside food and resident was not complaint with diet. Interventions included diet as ordered, snacks/supplements as ordered, honor food/fluid preferences, monitor weight as ordered, notify the physician (MD) of significant weight changes, labs as ordered. There was no mention of the resident's fluid restriction in the care plans developed for Resident #8. Residents Affected - Some 3. Medical record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included CKD unspecified heart failure, hypertension, and dementia without behavioral disturbance. Review of the MDS assessment, dated 06/19/21, revealed Resident #42 had moderately impaired cognition. Review of the care plan initiated on 03/03/20 revealed Resident #42 had CHF, hyperlipidemia, history of myocardial infarction, hypokalemia, and hypertension. Interventions included to check breath sounds, monitor for labored breathing, encourage adequate nutrition, give cardiac medications as ordered, monitor vital signs, monitor/document signs of malnutrition, and monitor/document/report signs and symptoms of CHF. There was no mention of the resident's fluid restriction in the care plans developed for Resident #42. Review of the physician orders, dated 09/22/20, revealed Resident #42 had a fluid restriction for 2,000 ml. total in 24 hours related to unspecified heart failure which included 1,080 ml. for dietary, and 920 ml. for nursing departments. 4. Medical record review for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), CHF, and CKD. Review of the MDS assessment, dated 06/27/21, revealed Resident #46 was cognitively intact. Review of the care plan, dated 03/18/19, revealed Resident #46 had altered cardiovascular status related to hypertension, CKD, CHF, and hypokalemia. Interventions included to administer medications as per order, assess for chest pain, encourage low salt/low fat diet, monitor and report abnormal vital signs/lung sounds, and educate resident/family regarding nature of disease and risk factors. There was no mention of the resident's fluid restriction in the care plans developed for Resident #46. Review of the physician orders, dated 06/30/20, revealed Resident #46 had a fluid restriction on 1,800 ml. total in 24 hours which included 960 ml. for dietary and 840 ml. for nursing departments. Interview on 07/20/2021 at 7:30 A.M. Registered Nurse (RN) #19 stated fluid restrictions were typically included in the dietary care plan which was updated by the dietician. RN #19 verified Resident #46, #42 and #8 had no interventions listed in the care plan which mentioned fluid restriction prior to the annual survey dated 07/19/21. The RN confirmed revisions were made to Resident #8s care plan for CHF on 07/19/21 for fluid restriction including history of resident non-compliance. On 07/20/21, RN #19 revised Resident #42 and #46's care plan to include fluid restriction interventions. 5. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, emphysema, osteogenesis imperfecta, and protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/21, revealed the resident had intact cognition. 365786 Page 3 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the physicians' order for Resident #4, dated 03/19/21, revealed an order to admit the resident to hospice services. Review of the comprehensive care plan, last reviewed on 05/17/21, revealed no care plan for hospice services were in place. Residents Affected - Some Interview on 07/22/21 at 10:20 A.M. with Registered Nurse (RN) #119 verified there was not an active hospice care plan in place for Resident #4. Review of the facility's policy titled Care Plan Documentation Guidelines, dated 2005, revealed staff developed a coordinated plan to provide appropriate care for each problem identified. 365786 Page 4 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

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. Based on observation, medical record review, and staff interview, the facility failed to ensure a revision was made to a resident' care plan for falls. This affected one (#53) of 19 residents reviewed for care plans. The facility census was 81. Findings include: Medical record review for Resident #53 revealed an admission date of 12/12/16. Diagnoses included arthropathy, muscle weakness, and atrial fibrillation. Review the annual Minimum Data Set (MDS) assessment, dated 07/01/21, revealed the resident was cognitively intact. Review of the care plan, dated 12/11/20, revealed the resident was at high risk for falls related to muscle weakness, diabetes, depression, heart disease, anemia, and chronic pain. Interventions included for staff to ensure the resident has slipper socks on when in bed, a floor mat by her bed, and non-skid socks always when not wearing shoes. Observations on 07/20/21 at 2:15 P.M. and on 07/21/21 at 1:15 P.M. revealed Resident #53 was in bed and had no fall mat in place and no non-skid socks on feet Observation on 07/21/21 at 1:24 P.M., revealed Licensed Practical Nurse (LPN) #78 and State Tested Nursing Aide (STNA) #108 witnessed Resident #53 getting out of bed with no non-skid socks on and no fall mat in place. The staff verified the findings. After surveyor intervention, STNA #108 took off the socks and placed non-skid socks on Resident #53. Interview on 07/21/21 at 1:25 P.M. with LPN #78 reported Resident #53's floor mat was supposed to be taken off the care plan due to the resident was self-ambulating out of bed without calling for assistance. LPN #78 reported Resident #53 was non-compliant with taking off her non-skid socks. Interview on 07/21/21 at 2:02 P.M. with Registered Nurse (RN) #19 reported Resident #53 was non-compliant with taking socks off or changing them while in bed. RN #19 was unable to provide a care plan for non-compliant with non-skid socks. RN #19 verified the care plan needed revised. 365786 Page 5 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interviews, the facility failed to provide activities of daily living (ADL) for for residents who were dependent on staff for their care. This affected three (#16, #39, and #277) of seven residents reviewed for ADLs. The facility census was 81 residents. Residents Affected - Few Findings include: 1. Record review for Resident #39 revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, multiple sclerosis, aphasia, hallucinations, epilepsy, and dementia. Review of the ADL plan of care, dated 01/09/21, revealed the resident was a two-person physical assistance for bathing. Review of the five-day Minimum Data Set (MDS) assessment, dated 07/14/21, revealed the resident had severely impaired cognition and required an extensive assistance of one staff person for bathing. Review of the facility's bath record for Resident #39 revealed a shower was given on 07/14/21 since readmission on [DATE]. The resident had not received any other bath or shower from 07/09/21 to 07/18/21. Observations on 07/19/21 at 2:29 P.M. revealed Resident #39 had greasy and stringy hair. The resident was unable to state when the last bath had been given. Interview with the Director of Nursing (DON) on 07/22/21 at 12:00 P.M. confirmed Resident #39 received one shower since readmission on [DATE]. 2. Review of Resident #16's medical record revealed an admission date of 10/23/13. Diagnoses included spastic quadriplegic cerebral palsy, cellulitis, insomnia, mood disorder, personality disorder, anxiety disorder, neuromuscular dysfunction of bladder, dysphagia, contracture of muscle and gastro-esophageal reflux disease. Review of the revised care plan, dated 11/22/19, revealed there were oral/dental health problems related to full dependency of oral care, poor salivary moistening/cleaning of mouth teeth, and lips. Interventions include for staff to routinely complete mouth inspections during shifts and provide care. Review of the Dental Summary Report for 360 care, dated 04/06/21, revealed Resident #21 was seen in his room, plague heavy, gingivitis and occlusal ware. The dentist requested for daily mouth care if possible. Resident #16 was to be brought to the dental clinic at the next visit. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/10/21, revealed Resident #39 was moderately impaired and was total dependent on activity of daily living with one-person physical assist for dental/oral care. Review of Resident #16's electronic record from 07/01/21 to 07/20/21 revealed personal hygiene ,which also included brushing of the teeth were not completed on every shift. There were no documented 365786 Page 6 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few initials on shifts from 2:00 P.M. to 10:00 P.M. for 07/01/21, 07/02/21, 07/04/21, 07/05/21, 07/06/21, 07/08/21, 07/12/21, 07/13/21, 07/14/21, 07/16/21, 07/17/21, 07/19/21, 07/20/21, and 07/21/21. For the shift 10:00 P.M. to 6:00 A.M. for 07/02/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/10/21, 07/11/21, 07/13/21, 07/14/21, 07/16/21, 07/17/21, 07/19/21 and 07/20/21. Observations on 07/21/21 at 11:00 A.M. and on 07/22/21 at 10:15 A.M. revealed the resident was sleeping. His mouth was opened and his teeth had an abundance of white substance layered on them. Interview on 07/21/21 at 12:33 P.M. with State Tested Nursing Aide (STNA) #59 explained how to read the shower sheets and personal hygiene sheets. STNA #59 stated if there were no initials next to the residents' name them a shower or personal hygiene care was not given, but if there were initials next to resident's name then they received a shower that day. Interview on 07/22/21 at 10:30 A.M. with Licensed Practical Nurse (LPN) #66 reported the resident received her shower last night and her teeth were brushed. LPN #66 reported STNAs and nurses brush Resident #16's teeth three to four times a day. Observation on 07/22/21 at 10:35 A.M., revealed Resident #16's mouth was opened and his teeth had an abundance of white substance layered on them. On 07/22/21 at 11:45 A.M. with the Director of Nursing (DON) verified the findings with no initials on the personal hygiene sheet. 3. Review of the medical record for Resident #277 revealed an admission date of 09/10/20. Diagnoses included cerebral infarction, syncope, chronic combine congestive heart failure, Alzheimer's disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/10/20, revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #277 was a two-person physical assist and required extensive assistance for bathing. Review of the care plan, dated 09/10/21, revealed Resident #277 had a self-care deficit related to cerebrovascular accident, osteoarthritis, spinal stenosis, anemia, edema, cellulitis, hypertension, and coronary artery disease. Interventions included two-person assistance with bathing. Review of the task documentation, dated September 2020, revealed Resident #277 received one shower on 09/18/20 during her stay at the facility from 09/10/20 to 09/18/20. The facility did not provide paper shower sheets dated from 09/10/20 to 09/18/20. Interview on 07/20/21 at 3:55 P.M. with State Tested Nurse Aide (STNA) #59 verified there was one shower documented for Resident #277 on 09/18/2020 for her entire stay at the facility from 09/10/20 to 09/18/20. STNA #59 stated the residents were scheduled to receive two showers per week, and showers were assigned according to room and bed location. STNA #59 stated the showers were always documented under the shower task and were specified not to be documented in the personal hygiene task. This deficiency substantiates Complaint Numbers OH00115930, OH00115775, OH00115560, and OH00111010. 365786 Page 7 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Potential for minimal harm Based on staff interview, employee record review, and review of facility's job description, the facility failed to ensure the Activity Director was a qualified activity professional to direct the provision of activities to the residents. This had the potential to affect all 81 residents residing in the facility. Residents Affected - Many Findings include: Review of the employee record for the Activity Director (AD) #34 revealed her date of hire was 06/01/20. There were no qualifications of an activity director in her employee record. Interview on 07/22/21 at 08:46 A.M. with AD #34 revealed she did not have her certification as an Activity Director or meet the education requirements to be a certified Activity Director of a nursing facility. AD #34 stated she was currently enrolled in an activity director course and plans to finish the course by October 2021. Interview on 07/22/21 at 02:00 P.M. with the Human Resource Manager (HRM) #16 confirmed the facility does not have a certified Activity Director at the facility. Review of the facility's job description titled Job Description: Activity Director, dated April 2021, confirmed the Activities Director must be certified (or willing to obtain certification within six months of employment). 365786 Page 8 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed ensure resident oxygen tubing was changed per the physician orders. This affected two (#12 and #35) of three residents reviewed for respiratory care. The facility identified 15 residents who utilized oxygen. The facility census was 81. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic respiratory failure with hypoxia, and other asthma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/08/21, revealed the resident was moderately cognitively impaired. Review of the physician's order, dated 06/21/21, revealed Resident #35 was ordered to have his oxygen tubing changed weekly. Review of the Treatment Administration Record (TAR), dated July 2021, revealed Resident #35 was ordered to change his oxygen tubing weekly every night shift, every Thursday. Resident #35 had his oxygen tubing changed on 07/08/21 and 07/15/21 according to the TAR. Observation of Resident #35's oxygen tubing on 07/19/21 at 10:10 A.M. revealed the oxygen tubing to be dated 07/08/21. Subsequent observation of Resident #35's oxygen tubing on 07/21/21 at 2:43 P.M. revealed the oxygen tubing to be dated 07/08/21. Interview with the Director of Nursing (DON) on 07/21/21 at 2:43 P.M. verified Resident #35's oxygen tubing to be dated 07/08/21. 2. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included transient ischemic attack (TIA) and hypoxemia. Review of the annual Minimum Data Set (MDS) assessment, dated 05/01/21, revealed the resident had intact cognition. Review of the physicians' order, dated 10/06/20, revealed an order to change oxygen tubing every seven days on night shift and to initial and date all tubing. Observation on 07/19/21 at 9:10 A.M. of the oxygen tubing connected to the concentrator of Resident #12 revealed the tubing had a piece of tape which contained the date of 07/08/21 and no initials. The tubing was placed in the nose of Resident #12 and was on delivering oxygen. Interview with Registered Nurse (RN) #63 on 07/19/21 at 9:10 A.M. verified the oxygen tubing for Resident #12 contained the date of 07/08/21 and was not initialed. 365786 Page 9 of 10 365786 07/22/2021 Villa Georgetown Rehabilitation and Healthcare Cen 8065 Dr Faul Road Georgetown, OH 45121

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and record review, the facility failed to maintain laundry dryers in a safe manner and prevent a build up of dryer lint in the facility dryers. This had the potential to affect all 81 residents who resided in the facility. Residents Affected - Many Findings include: Observation on 07/22/21 at 11:28 A.M. of Dryer #2 lint screen revealed lint hanging from the lint screen and balled up in the base of the dryer. Interview on 07/22/21 at 11:28 A.M. with Laundry #58 confirmed the lint had built up in the dryer. Laundry #58 stated the dryers were cleaned tree times a day of dryer lint. Observation on 07/22/21 at 11:40 A.M. with Maintenance Director #500 revealed a build up of lint in Dryer #1 with lint collected in soccer size balls under Dryer #1. Interview on 07/22/21 at 11:40 A.M. with the Maintenance Director #500 verified the large amount of lint collected until Dryer #1. He stated the lint trap should be cleaned after every three loads and stated the new linens the facility received gave off more lint than older linens. Review of the laundry staff lint trap signed out sheet revealed the staff signed once a day for dryer lint trap clean out. There was a noted on the sign out sheet stating the staff were to clean the dryer lint traps after every three loads. 365786 Page 10 of 10