Health inspection·June 30, 2022

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 staff interview, medical record review, and review of facility policy, the facility failed to ensure care conferences were held with the interdisciplinary team and resident and/or resident representative. This affected one (Resident #2) out of one resident reviewed for care plan conferences. The facility census was 74. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/18. Diagnoses included heart failure, diabetes type two, functional paraplegia, dementia, and seizure disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of Resident #2's Care Conference Summary form dated 03/21/22 revealed the only documented attendees from the facility included social services and activities. Several sections of the interdisciplinary care conference form were left blank. Interview on 06/13/22 at 10:05 A.M. with Resident #2 revealed the facility has not held interdisciplinary care conferences with her and/or her family. Interview on 06/16/22 at 9:27 A.M. with Social Services (SS) #96 revealed no members from the nursing or clinical team attended the care conference. SS #96 verified much of the care confererenc summary form was left blank as she was only able to fill out some of the sections, and many sections of the form were outside of her scope of practice. Review of the facility policy titled Care Conference Policy and Procedure, dated 04/2022, revealed the facility would hold care conference meetings with residents and representatives and the interdisciplinary team to discuss goals, choices, discharge plans, advanced care planning and advanced directives. Page 1 of 25 365799 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, and review of facility policy, the facility failed to maintain a clean and sanitary environment in resident rooms. This affected four residents (Resident #26, #37, #61, and #63) out of 74 residents in the facility. Additionally, the facility failed to maintain an odor free environment in the hallway of the teal unit. This had the potential to affect all 24 residents living on the teal unit (#2, #3, #8, #9, #11, #18, #22, #25, #26, #27, #32, #33, #35, #37, #40, #41, #47, #49, #54, #59, #61, #63, #64, and #67). Additionally, the facility failed to maintain a clean and safe environment in the front of the facility grounds. This had the potential to affect all 74 residents. The facility census was 74. Findings include 1. Review of the medical record for Resident #26 revealed an admission date of 04/26/17. Diagnoses included hemiplegia, dementia, epilepsy, and bipolar disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had significant cognitive impairment. Review of the medical record for the Resident #63 revealed an admission date of 07/22/19. Diagnoses included dementia without behaviors, unspecified psychosis, and major depression. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #63 had significant cognitive impairment. Observation on 06/13/22 at 1:41 P.M. revealed Resident #26 and Resident #63's room was dirty with black residue around the edges of the bedroom and bathroom. The bathroom floor also had two drips of a thick brown substance which were approximately the size of a nickel and quarter. Observation on 06/14/22 at 12:17 P.M. revealed Resident #26 and Resident #63's room was dirty with black residue around the edges of the bedroom and bathroom. The bathroom floor also had two drips of a thick brown substance which were approximately the size of a nickel and quarter. Observation on 06/15/22 at 8:53 A.M. revealed Resident #26 and Resident #63's room was dirty with black residue around the edges of the bedroom and bathroom. The bathroom floor also had two drips of a thick brown substance which were approximately the size of a nickel and quarter. Observation on 06/16/22 at 9:38 A.M. revealed Resident #26 and Resident #63's room was dirty with black residue around the edges of the bedroom and bathroom. The bathroom floor also had two drips of a thick brown substance which were approximately the size of a nickel and quarter. Interview on 06/16/22 at 9:45 A.M. with Housekeeping Manager (HM) #62 confirmed Resident #26 and Resident #63's room floor was sticky and shoes stuck to the floor when walking in the resident rooms. She revealed the old floor cleaner would cause the floors to get sticky, so they were currently only using water to clean resident room floors. HM #62 revealed the floors need to be stripped, but she had not trained staff to use the cleaner required and had not stripped the floors to remove the caked on blackish brown residue on the edges of the room and in doorways. HM #62 also revealed the 365799 Page 2 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility had floor scrapers that could be used to get the brown drops off the floor if mopping did not work. She confirmed Resident #26 and Resident #63's room floor was dirty and appeared to not have been cleaned in several days. 2. Review of the medical record for Resident #37 revealed an admission date of 07/29/21. Diagnoses included cerebral infarct, hemiplegia, and aphasia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #37 had significant cognitive impairment. Review of the medical record for the Resident #61 revealed an admission date of 08/04/21. Diagnoses included dementia with behaviors, failure to thrive, depression, and degeneration of the brain. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #61 had mild cognitive impairment. Observation of Resident #37 and Resident #61's room on 06/13/22 at 10:46 A.M. revealed a hole in the bathroom door which was approximately the size of a baseball. The observation further revealed the floor to the bathroom was dirty and the toilet bowl had brown splattering on the seat and inside of the toilet bowl. Observation of Resident #37 and Resident #61's room on 06/14/22 at 12:18 P.M. revealed a hole in the bathroom door which was approximately the size of a baseball. The observation further revealed the floor to the bathroom was dirty and the toilet bowl had brown splattering on the seat and inside of the toilet bowl. Observation of Resident #37 and Resident #61's room on 06/15/22 at 8:56 A.M. and again at 11:20 A.M. revealed a hole in the bathroom door which was approximately the size of a baseball. The observation further revealed the floor to the bathroom was dirty and the toilet bowl had brown splattering on the seat and inside of the toilet bowl. Observation of Resident #37 and Resident #61's room on 06/16/22 at 9:39 A.M. revealed a hole in the bathroom door which was approximately the size of a baseball. The observation further revealed the floor to the bathroom was dirty and the toilet bowl had brown splattering on the seat and inside of the toilet bowl. Interview on 06/16/22 at 9:50 A.M. with Housekeeping Manager (HM) #62 confirmed Resident #37 and Resident #61's room had a strong smell of urine. HM #62 revealed one of the residents urinates on the floor. HM #62 revealed the facility had no process to ensure extra cleaning of Resident #62 and Resident #37's room. Interview on 06/16/22 at 5:20 P.M. with State Tested Nurse Aide (STNA) #116 confirmed the bathroom door in Resident #61 and Resident #37's room had a hole in it which was approximately the size of a baseball. STNA #116 was not sure how the hole developed and how long it had been there. Review of housekeeping checklist revealed resident rooms and bathrooms should be cleaned daily which included sweeping and mopping the floor as well as cleaning the toilet. 3. Observation on 06/14/22 at 4:15 P.M. revealed a pungent smell of urine in the hallway of the 365799 Page 3 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0584 Teal unit. Level of Harm - Minimal harm or potential for actual harm Interview on 06/14/22 at 4:17 P.M. with Registered Nurse (RN) #108 revealed it smelled like it normally does which was like urine and feces. RN #108 revealed residents do not like drinking water and sometimes their pee smells very strong. RN #108 revealed the soiled linen closet was likely where the smell was coming from as it was where they put all the dirty diapers. Residents Affected - Many Review of the facility policy titled Environmental Routine Room Cleaning, dated 12/29/21, revealed staff will provide consistent cleaning routines for resident rooms and common areas. 4. Observation of the facility on 06/13/22 at 8:00 A.M. revealed several cigarette butts on the ground outside the front door. The butts were located on the sidewalk, in a pile of dead leaves under a wooden bench, in the mulch, and in the grass. There was a sign in the area that read no smoking. Observation and interview on 06/16/22 at 9:50 A.M. with Housekeeping Manager (HM) #62 confirmed cigarette butts were scattered outside of the facility entrance on the ground (approximately 50 cigarette butts). The cigarette butts were located on the sidewalk, in a pile of dead leaves under a bench, in the mulch, and in the grass. The temperature outside had ranged from 90 degrees to 97 degrees during the week of the survey. HM #62 revealed residents do not smoke outside by the front door. HM #62 revealed it was unacceptable to have the sidewalk littered with cigarette butts especially due to the heat and fire hazard with the hot weather. Observation on 06/23/22 at 12:30 P.M. revealed a staff member sitting outside, smoking in a non-smoking area, The observation further revealed the staff member left the cigarette butt on the ground outside the front door. 365799 Page 4 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

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 staff interview, medical record review, and review of facility policy, the facility failed to ensure care conferences were held with the interdisciplinary team and resident and/or resident representative. This affected one (Resident #2) out of one resident reviewed for care plan conferences. The facility census was 74. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/18. Diagnoses included heart failure, diabetes type two, functional paraplegia, dementia, and seizure disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of Resident #2's Care Conference Summary form dated 03/21/22 revealed the only documented attendees from the facility included social services and activities. Several sections of the interdisciplinary care conference form were left blank. Interview on 06/13/22 at 10:05 A.M. with Resident #2 revealed the facility has not held interdisciplinary care conferences with her and/or her family. Interview on 06/16/22 at 9:27 A.M. with Social Services (SS) #96 revealed no members from the nursing or clinical team attended the care conference. SS #96 verified much of the care confererenc summary form was left blank as she was only able to fill out some of the sections, and many sections of the form were outside of her scope of practice. Review of the facility policy titled Care Conference Policy and Procedure, dated 04/2022, revealed the facility would hold care conference meetings with residents and representatives and the interdisciplinary team to discuss goals, choices, discharge plans, advanced care planning and advanced directives. 365799 Page 5 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interviews, resident emergency contact interview, review of the hospital history and physical, review of continuity of care, review of hospital ethics team meeting notes, review of a hospital discharge summary, review of a hospital transfer report, review of facility policy related to code status, and review of a facility policy related to Cardiopulmonary Resuscitation (CPR), the facility failed to initiate CPR and contact Emergency Medical Services (EMS) for one resident (Resident #73) who was a Full Code status and was found unresponsive without vital signs. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death, when facility staff did not immediately initiate CPR on Resident #73 nor contact EMS to assist in life-sustaining measures and expired at the facility. This affected one (#73) of four residents reviewed for death. The facility identified 44 residents who were a Full Code status. The facility census was 74. On [DATE] at 2:08 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse #120, and Corporate Assistant Director of Nursing #79, were notified that Immediate Jeopardy began on [DATE] at approximately 6:15 P.M. when Resident #73 was found by State Tested Nursing Assistant (STNA) #75 lying in bed unresponsive. Registered Nurse (RN) #108 was notified and assessed Resident #73 to have no respirations and no pulse; however, there were no life-sustaining measures initiated nor EMS contacted for this resident who was identified as having a Full Code status. Physician #125 was notified, and an order was given to release Resident #73 to the funeral home. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: • On [DATE], a facility-wide audit of all resident's was completed by the DON, to ensure accuracy of advance directives documentation in the medical records as well as verification of code status orders, care plan documentation and a signed Do Not Resuscitate (DNR) form, if applicable. There were no additional identified concerns. • Between [DATE] at 2:30 P.M. and [DATE] at 2:10 P.M., all staff (nurses, aides, dietary, housekeeping, therapy, etc.) including agency staff were in-serviced on the policies and procedures. The training included education on CPR and Advanced Directives and included a post-test to confirm knowledge. The training was completed by the DON or designee. • On [DATE] and [DATE], the Continuity of Care (COC) was verified with current code status for the most recent new admissions (Resident #03, #29, #39, #64, #295, and #296) and four additional residents (Resident #01, #13, #52, and #66) with no discrepancies found. • On [DATE] and [DATE], all Registered Nurse (RN) and Licensed Practical Nurse (LPN) employee files 365799 Page 6 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0678 were audited for CPR certification by the DON or designee. All certifications were found to be current and active. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] and [DATE], education was provided to facility Physicians, and Certified Nurse Practitioners (CNP) by the DON, and audits were completed on Physician, CNP, and Physician Assistant (PA) documentation for completeness and accuracy. The audits were completed by the DON. • On [DATE] from 1:32 P.M. to 1:45 P.M. eight staff (STNA #126, STNA #130, STNA #132, STNA #133, Dietary staff #63, Activities staff #35, RN #34, and RN #108) were interviewed regarding CPR and Advanced Directives, and all staff except for STNA #133 were found to have completed the education and were knowledgeable regarding the topics. Upon identification, STNA #133 immediately received education by the DON or designee on [DATE] regarding CPR and Advanced Directives. • On [DATE] at 4:00 P.M., seven additional charts (Residents #17, #26, #29, #38, #65, #66, and #294) were audited for accuracy of code status orders with COC documentation from admission or readmission with no errors found. • Starting on [DATE], audits of all new admissions and random audits of resident code status with the COC documentation will be completed five times per week for four weeks, then twice weekly for four months, then as needed. Audits will be completed by the unit manager or designee. • Starting on [DATE], all new hires and agency staff will be educated on CPR and Advanced Directives prior to working their first shift on the floor. This education will be provided by the unit manager or designee. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and are monitoring for on-going compliance. Findings include: Review of the closed medical record for Resident #73 revealed an admission date of [DATE]. Diagnoses included coronary artery disease, diabetes, hypertension, myocardial infarction, and contractures of the upper and lower extremities. Resident #73 was sent to the hospital on [DATE] and re-admitted to the facility on [DATE]. Resident #73 passed away on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had significant cognitive impairment and required extensive assistance of two staff for transfers and activities of 365799 Page 7 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0678 daily living. Level of Harm - Immediate jeopardy to resident health or safety Review of a hospital psychiatry note dated [DATE] revealed Resident #73's mental capacity was assessed, and it was determined Resident #73 lacked the capacity to make complex medical decisions. Residents Affected - Few Review of a DNR form dated [DATE] revealed Resident #73's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #73's facility physician orders revealed an order dated [DATE] to [DATE], which indicated Resident #73's code status was DNRCC. Review of the hospital history and physical, dated [DATE] revealed Resident #73 presented to the hospital with osteomyelitis of the bilateral feet and toe pain and increased discharge from her right foot and foul smell. Resident #73 was being evaluated for a second opinion for medical management and surgery which was not offered as an option due to several large bedsores and likely breakdown of the amputation stumps. The hospital physician spoke with Resident #73's emergency contact and was informed Resident #73 had three children living in Poland. The emergency contact revealed Resident #73's family had removed her from hospice. The physician documented staff needed to determine Legal Next of Kin (LNOK) which consisted of Resident #73's sons to discuss goals of care. Review of Resident #73's hospital COC, revealed a demographics sheet dated [DATE] which identified Resident #73's code status was Full Code. Review of Resident #73's hospital Ethics Team Meeting Notes dated [DATE] revealed the medical team would prefer to provide compassionately supportive care to Resident #73 and not continue with painful and disruptive medical interventions. The Ethics team revealed Resident #73's decision makers had expressed a desire to have everything done and were not interested in hospice care. The Ethics team's final recommendations included continuing appropriate medical therapy for Resident #73 and continue speaking with family regarding goals of care. Review of Resident #73's hospital Discharge summary dated [DATE] revealed Resident #73's LNOK were her sons who lived in Poland. The hospital physician had discussions with Resident #73's family and reported they want everything done that could possibly extend her lifespan. She was made a Full Code. The Ethics team consult determined, the end result was clear to the medical team . medical therapy should be continued. The goal was for continued family meetings to communicate with family and inform them interventions will not improve Resident #73's quality of life. The hospital discharge summary revealed upon discharge Resident #73's code status will be Full Code. Review of Resident #73's physician order from the hospital dated [DATE] revealed Resident #73 was a Full Code. The start time for the order was [DATE] at 11:27 A.M. and the end time stated, until specified. Review of Resident #73's transfer report from the hospital dated [DATE] to [DATE] revealed Resident #73's code status was a Full Code upon discharge. Review of Resident #73's facility physician orders revealed no orders for code status were written upon Resident #73's return from the hospital on [DATE] and there were no current physician orders for code status in the electronic medical record at the time of Resident #73's death on [DATE]. 365799 Page 8 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Nurse Practitioner #127 visit note dated [DATE] revealed Resident #73 was previously on hospice, but the family had only agreed to Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) at that time. The note further revealed there were multiple attempts by the hospital and facility staff to reach family which were unsuccessful. Review of the progress note dated [DATE] revealed Resident #73 was found unresponsive and was assessed by two nursing staff (RN #108 and LPN #22) with findings of no pulse or respirations. Nurses reported Resident #73 was a DNRCC and the funeral home was contacted. Interview on [DATE] at 11:27 A.M. with the DON, revealed the facility had a difficult time getting in touch with Resident #73's family and used Resident's #73's friend and emergency contact as her decision maker. The DON revealed after a hospitalization, the orders should be entered automatically into the resident's medical chart. If the hospital changed the physician orders, then the admitting staff should contact the physician about the change. The DON confirmed no orders were placed for code status upon return from the hospital and confirmed the order from [DATE] to [DATE] for DNRCC had been discontinued due to discharge to the hospital on [DATE]. The DON confirmed there was no documentation of attempts to contact Resident #73's family. The DON revealed her expectations for staff would be to check code status, and if unable to find a code status or verify the code status, then staff should initiate CPR. Interview on [DATE] at 11:56 A.M. and again at 12:14 P.M. with RN #108 revealed STNA #75 found Resident #73 unresponsive when passing trays for dinner. RN #108 revealed Resident #73 had eaten lunch and when done with lunch, RN #108 and STNA #75 completed extensive wound care and dressing changes. RN #108 revealed the next time Resident #73 was seen was when she was found unresponsive. RN #108 revealed Resident #73's wound care was completed around 3:00 P.M. and she was found around 6:15 P.M. by STNA #75. RN #108 revealed when she entered the room to assess Resident #73, she was unresponsive and upon assessment had no respirations or pulse, and felt cold to touch. RN #108 revealed Resident #73 had upper and lower extremity contractures. RN #108 denied observing pooling of blood or dependent lividity. RN #108 revealed Resident #73 was DNRCC and revealed she verified by looking in the medical record and saw the signed DNRCC physician form dated [DATE]. RN #108 revealed no knowledge of Resident #73 having had a change in code status while at the hospital and upon return to the facility. Interview on [DATE] at 12:10 P.M. with LPN #22 revealed she was informed of the death of Resident #73 by RN #108. RN #108 asked her to assess Resident #73 for death confirmation. LPN #22 revealed Resident #73 was unresponsive and did not have respirations or pulse. LPN #22 revealed she did not touch Resident #73 and reported Resident #73 was covered up to the chest with a blanket. Interview on [DATE] at 2:50 P.M. with Resident #73's friend and emergency contact revealed she spoke with the facility about Resident #73's code status after a hospital discharge in [DATE] when hospice was being discussed. She revealed she spoke with hospital staff about the change from DNRCC to DNRCCA when Resident #73 was removed from hospice around [DATE], but denied knowledge of additional conversations. She revealed she was informed by the facility that Resident #73's sons had not been in contact with the hospital in [DATE] and denied the facility having any conversations with her related to Advanced Directives or code status after Resident #73's return from the hospital on [DATE]. Interview on [DATE] at 3:28 P.M. with Physician #125 revealed Physician #125 had no knowledge of an order not having been placed in the medical record for Resident #73's code status. Physician #125 revealed he would have made her DNRCC due to her condition even if the hospital and family had 365799 Page 9 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few changed her code status to Full Code. Physician #125 revealed he knew Resident #73 well and knew what was best for her as her family was not involved and had a language barrier and a lack of medical understanding. Interview on [DATE] at 5:29 P.M. with CNP #127 revealed she did not remember if her comment in her progress note dated [DATE] (previously evaluated and deemed poor surgical candidate, given antibiotics. Was previously on hospice for same presentation, however son was only agreeable to DNRCC-A, multiple attempts by hospital staff and facility staff to reach son to discuss code status and unable to reach son) was referring to updates from [DATE] when hospice was discussed or from after her most recent hospitalization in [DATE]. CNP #127 revealed she typically reads through the hospital paperwork and talks with staff to confirm information after a readmission to the facility. CNP #127 revealed she reviewed Resident #73's hospital paperwork from her readmission, but did not remember the paperwork stating changes to code status. CNP #127 revealed she was informed by nursing staff Resident #73's code status was DNRCC. Review of the facility policy titled Advanced Directives Care planning, dated 11/2020, revealed the facility gives residents and representatives the opportunity to discuss their goals for care planning including preference for advanced directives. The policy also revealed it is the centers responsibility to respect the wishes of their patients and residents as it relates to their goals of care and advanced directives. The policy also revealed the physician would be notified of the resident or representatives advanced directive wishes and the physician or designee completes updated code status paperwork or ordered as needed. The documents are to be filed in the medical record and updated on an ongoing basis. Review of the facility policy titled CPR-Cardiopulmonary Resuscitation (for nursing centers), dated [DATE], revealed the facility would provide CPR in accordance with the American Heart Association guidelines to residents who experience respiratory and/or cardiac arrest unless the resident had a current and valid DNR. The policy revealed the DNR orders would be maintained in the resident's medical record. Once the facility determined a resident to be pulseless or unresponsive a licensed staff member should initiate appropriate emergency measures. The policy stated if there was not a valid DNR order in the medical record, CPR shall be continued until EMS arrive and assume responsibility of the resident. 365799 Page 10 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a fall investigation, and staff interviews, the facility failed ensure staff utilized proper precautions while ambulating with residents. Actual harm occurred when State Tested Nurse Aide(STNA) #126 was ambulating with Resident #64, while not using a gait belt, and Resident #64 fell resulting in a left hip fracture and subsequent hospitalization. This affected one (Resident #64) out of seven residents reviewed for falls. The facility census was 74. Findings include Review of the medical record for Resident #64 revealed an admission date of 11/19/21. Diagnoses included dementia, weakness, spinal stenosis, and depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had significant cognitive impairment, and required extensive assistance of two staff members for bed mobility and transfers. Review of the Care Plan dated 12/03/21, with handwritten updates, revealed Resident #64 was at risk for falls with interventions for staff to use a gait belt (an assistive device used to assist with transfers) during transfers. Review of the Fall Investigation for Resident #64 dated 04/06/22 revealed Resident #64 was walking with STNA #126 from the bathroom to her bed with the use of her walker. Resident #64 removed her hand from her walker to point at her roommate, fell backward, and hit her head, left leg, and hip. Staff started neurological checks and informed the physician of Resident #64's complaints of pain to her left hip. The physician ordered an x-ray which showed a fractured hip. Resident #64 was then sent out to the hospital and required surgery. Interventions put in place included an all-staff training to always use a gait belt when assisting residents with transfers and ambulation. A skin assessment revealed Resident #64 had a bump to her head as well as a hip injury. A pain assessment determined Resident #64 had pain to the left hip. Review of hospital discharge paperwork revealed Resident #64 was admitted to the hospital with a closed left hip fracture. Further review of the hospital discharge paperwork revealed x-rays were completed and revealed an acute comminuted intertrochanteric fracture of the left femur with surgical revision of a left TFNA (proximal femoral nailing system) for intertrochanteric femoral fracture. Interview on 06/16/22 at 12:45 P.M. with the Director of Nursing (DON) revealed the intervention put in place for Resident #64 after her fall with injury on 04/06/22 was for staff to use gait belts when transferring and ambulating with Resident #64. The DON also revealed this was a standard of care for their corporation and all staff were expected to be using gait belts for all residents prior to Resident #64's fall. The DON revealed an all-staff training was completed due to the incident with Resident #64, since STNA #126 was not using a gait belt during the ambulation when Resident #64 fell and fractured her hip. Interview on 06/16/22 at 3:10 P.M. with STNA #126 revealed Resident #64 was in the bathroom and STNA #126 was assisting Resident #64 back to her bed when Resident #64 looked up, pointed at her roommate, said look, and fell. STNA #126 revealed out of reaction, she looked up, lost her concentration, 365799 Page 11 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0689 Level of Harm - Actual harm Residents Affected - Few and Resident #64 fell backwards and hit her head as well as injured her leg and hip. STNA #126 revealed Resident #64 immediately verbalized pain, her foot was turned out in an unnatural position, and Resident #64 was transferred to the hospital. STNA #126 revealed prior to the fall, Resident #64 was a one person assist by staff when using her walker but would use her wheelchair for longer distances. STNA #126 revealed staff were reeducated after the fall that staff should use a gait belt for all residents when assisting with transfers and ambulation. STNA #126 verbalized the use of a gait belt when assisting residents was an expectation for staff prior to the fall. STNA #126 revealed she did not use a gait belt during the event when Resident #64 fell and was injured but could not remember why. STNA #126 revealed since the fall, Resident #64 had been working with therapy on ambulating, but was only able to transfer with staff at that time. Interview on 06/16/22 at 4:30 P.M. with the DON revealed the facility does not have a specific policy related to use of the gait belts, but revealed they use therapy guidelines which recommend using a gait belt for all resident transfers and during ambulation. 365799 Page 12 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0692 Provide enough food/fluids to maintain a resident's health. 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, observation, staff interview, and facility policy review, the facility failed to ensure therapeutic diets were provided as ordered. This affected one (Resident #223) out of one resident reviewed for dialysis. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record for Resident #223 revealed an admission date of 06/07/22. Medical diagnoses included type two diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Review of the physician orders for June 2022 revealed Resident #223 had an order dated 06/09/22 for a regular, renal diet with no added salt and thin liquids. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #223 had intact cognition. Resident #223 required extensive assistance from two staff to complete activities of daily living. Resident #223 was noted to be on a therapeutic diet. Review of Resident #223's progress notes dated from admission through the time of the survey revealed on 06/15/22 at 3:14 P.M., after the surveyor observed the lunch meal service on 06/15/22, Dietitian #129 reported the hospital discharge diet orders on 06/07/22 was a regular, controlled carbohydrate diet. The kitchen was notified of the diet and admission. An order for a regular, renal, and no added salt diet was placed in the medical record on 06/09/22 related to a diagnosis of end stage renal disease and hemodialysis. The diet was clarified with the physician on 06/15/22 and was to be regular, carbohydrate controlled, and no added salt. Review of the baseline care plan dated 06/07/22 revealed Resident #223 was on a renal diet. The care plan was updated to reflect the diet was changed to controlled carbohydrate and no added salt on 06/16/22, after the surveyor observed the lunch meal service on 06/15/22. Observation of the lunch meal service on 06/15/22 revealed no renal diets were prepared for the lunch meal. Interview on 06/15/22 at 12:57 P.M. with Dietitian #129 confirmed Resident #223 was not served a renal diet for lunch. Dietitian #129 stated she was not aware Resident #223 had a renal diet ordered and had not received any meals since admission based on a renal diet order. Review of the facility policy titled Hemodialysis-Nursing Operational Policy/Procedure, dated 12/11/14, revealed the policy stated, the staff will assess the hemodialysis patient as needed and notify the physician or certified nurse practitioner with changes, note the orders and complete documentation in the medical record or on the communication form. The center's policy is to assess, monitor and care for our hemodialysis patients/residents per the plan of care, developed by the interdisciplinary team under the direction of the physician and the clinical best practices. 365799 Page 13 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy recommendations, staff interview, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed and a rationale was provided when a pharmacy recommendation was declined. This affected two residents (Residents #2 and #16) out of six reviewed for unnecessary medications and pharmacy recommendations. The facility census was 74. Findings include: 1. Review of the medical record for Resident #16 revealed an original admission date of 09/19/19 and a readmission date of 02/22/22. Medical diagnoses included paranoid schizophrenia, type two diabetes mellitus with hyperglycemia, major depressive disorder, hallucinations, unspecified psychosis, Bipolar disorder, anxiety disorder, and chronic kidney disease stage three. Review of the physician orders for June 2022 revealed Resident #16 had an order dated 04/10/21 for a complete metabolic panel (CMP), liver function, and hemoglobin A1C (lab used to determine average blood glucose levels over the past few months) labs to be completed every six months (180 days) with instructions to notify the physician and document. The order did not include a lipid panel or a complete blood count (CBC) lab. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderately impaired cognition. Review of the pharmacy recommendation dated 11/08/21 revealed Resident #16 received antipsychotic medication and there was a recommendation for the following labs to be completed every six months: Basic Metabolic Panel (BMP) or Complete Metabolic Panel (CMP), fasting blood glucose or hemoglobin A1C, liver function tests, a lipid panel, and a complete blood count (CBC). The physician disagreed with the recommendation but did not a rationale. The physician signed the recommendation and dated it 11/10/21. Review of the Care Plan revised 02/28/22 revealed Resident #16 was at risk for adverse side effects from medications with interventions including monitor labs as ordered and report results to physician. Interview on 06/16/22 at 7:34 P.M. with the Director of Nursing (DON) confirmed the physician did not provide any rationale for disagreeing with the pharmacy recommendation for Resident #16. 2. Review of the medical record for Resident #2 revealed an admission date of 01/02/18. Diagnoses included heart failure, transient ischemic attack, gastrointestinal bleed, diabetes type two, functional paraplegia, dementia, hip fracture, and seizure disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of pharmacist medication review dated 08/11/21 revealed Resident #2 was prescribed primidone (anticonvulsant medication) and depakote (anticonvulsant medication) and recommended to check primidone and phenobarbital levels as well as depakote levels every six months. The physician signed the form on 08/27/21, marked agree, and wrote VPA level ordered today. No comments were made addressing 365799 Page 14 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the recommendation regarding the primidone and phenobarbital levels. The facility obtained a depakote (VPA) level on 08/30/21 and again on 01/24/22. The facility had no records of the primidone or phenobarbital lab having been ordered or completed. Interview on 06/16/22 at 12:12 P.M. with Physician #125 revealed he receives the pharmacy recommendation forms from the facility and reviews them each month. He revealed he would talk with the family, nursing staff, and other disciplines when making decisions regarding a recommendation. Physician #125 revealed he would only be concerned about ordering phenobarbital and primidone levels for a resident with a history of seizures and revealed he was unaware Resident #2 had a seizure disorder. Interview on 06/16/22 at 12:45 P.M. with the DON confirmed Resident #2's pharmacy recommendation dated 08/11/21 did not give instructions or a rationale as to why the additional labs (primidone and phenobarbital level) were not ordered and confirmed the form was not fully completed. Review of facility policy titled Pharmacy Specialty: Consultant services, undated, revealed irregularities would be acted upon by the prescribing or attending physician. 365799 Page 15 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, observations, and review of facility policy, the facility failed to ensure that its medication error rate was less than five percent. This affected two (#58 and #17) out of four residents reviewed for medications. There was 25 opportunities with two errors resulting in an eight percent (%) medication error rate. The facility census was 74. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #58 revealed an admission date of 05/02/22. Diagnoses included vitamin B deficiency and iron deficiency anemia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/08/22, revealed Resident #58 had severely impaired cognition. Review of the Plan of Care, dated 05/23/22, revealed Resident #58 had alteration in cardiac status related to orthostatic hypotension, hypertension, congestive heart failure, atherosclerosis, chronic obstructive pulmonary disease, vitamin B deficiency, and hypercalcemia. Interventions included administration of medications as ordered. Review of Resident #58's physician orders for June 2022 revealed an order dated 05/02/22, with a start dated of 05/03/22, for half of a tablet of 500 microgram (mcg) of vitamin B-12 for supplementation. The order was discontinued after the medication administration observation on 06/14/22. Observation on 06/14/22 at 9:25 AM revealed Licensed Practical Nurse (LPN) #64 administered a whole 500 mcg tablet of vitamin B-12 to Resident #58 during medication administration. Review of Resident #58's progress notes revealed on 06/14/22 at 7:22 P.M. (after the medication observation) the Director of Nursing (DON) documented the resident's vitamin B-12 order was clarified with the Medical Director (MD) and a new order for vitamin B-12 500 mcg twice daily was received. 2. Review of the medical record for Resident #17 revealed an admission date of 04/07/22. Diagnoses included diabetes mellitus type two, right sided hemiplegia following cerebral infarction, and arthritis. Review of the quarterly MDS assessment, dated 06/09/22, revealed Resident #17 had intact cognition and required supervision to limited assistance of one staff for all activities of daily living. Review of the Plan of Care dated 04/25/22 revealed Resident #17 had an alteration in cardiac status related to hypertension, history of cerebral vascular accident, diabetes mellitus, hyperlipidemia, hypothyroidism, chronic hepatitis, and asthma. Interventions included administration of medications per orders. Review of Resident #17's physician orders for June 2022 revealed an order dated 04/11/22, with a start date of 04/12/22, for 81 milligrams (mg) of eccentric coated (EC) or delayed release (DR) aspirin. Observation on 06/14/22 at 9:40 AM revealed 81 mg of chewable aspirin was prepared for Resident #17 during a medication administration by LPN #64. In addition to the aspirin, LPN #64 prepared the 365799 Page 16 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remainder of Resident #17's ordered medications. The resident was found to be unavailable for the medication administration at 9:48 A.M., and LPN #64 placed Resident #17's name on the medication cup and placed the medication cup into the medication cart for administration later. Resident #17's medication, including the chewable aspirin, was administered to Resident #17 at 10:30 A.M. when she returned to her room from outside. Immediately following the medication administration, LPN #64 confirmed Resident #17 was administered a chewable aspirin instead of the ordered EC aspirin. Review of the facility policy titled Medication Administration, undated, revealed the Medication Administration Records (MAR) were utilized during a medication pass to verify the medication name, dose, and directions on the medication label match the medication order transcribed in the MAR. Resident availability and willingness to receive medications should be assessed prior to preparing medication for administration. Medication was to be prepared for one resident at the time of administration. Pre-pouring medication was not a recommended standard of practice. 365799 Page 17 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and facility policy review, the facility failed to store medications in a safe and secure manner. This affected three residents (#66, #30, and #2) out of three residents reviewed for medication storage. The facility census was 74. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 08/23/21. Diagnoses included chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/03/22, revealed Resident #66 had intact cognition and no evidence of behaviors. Resident #66 required supervision of one staff for all activities of daily living. Review of Resident #66's physician orders for June 2022 revealed an order dated 09/02/21 for 18 micrograms (mcg) of Spiriva to be inhaled daily for COPD. Further review of the orders revealed an order dated 09/12/22 for one puff of Advair diskus 250-50 mcg/dose twice daily for COPD. Review of the Plan of Care dated 09/20/21 revealed Resident #66 had the potential for respiratory distress related to COPD, nicotine dependence, and inability to lay flat due to shortness of breath (SOB). Interventions included administration of medications per physician orders. Observation on 06/13/22 at 10:08 AM of Resident #66 revealed a Spiriva inhaler (used to treat lung diseases such as asthma and COPD, bronchitis, and/or emphysema. It must be used regularly to prevent wheezing and shortness of breath) and Advair inhaler (used to control and prevent symptoms such as wheezing and shortness of breath caused by asthma or ongoing lung disease such as COPD, which includes chronic bronchitis and emphysema) on her bedside table. Her bedside table was next to her bed, where she was lying, without a licensed medical professional present. Interview on 06/13/22 at 10:28 AM with Licensed Practical Nurse (LPN) #106 confirmed Resident #66's inhaler medications were left at Resident #66's bedside without a licensed medical professional present. She revealed the facility policy was to administer medications and store medications in a safe and secure location when not in use, which did not include at the resident's bedside. 2. Review of the medical record for Resident #30 revealed an admission date of 04/11/22 and a discharge home against medical advice (AMA) on 06/17/22. Diagnoses included cerebral infarction (stroke) and hypertension (HTN). Review of the comprehensive MDS assessment, dated 04/17/22, revealed the resident had intact cognition. Resident #30 required limited to extensive assistance of one to two or more staff for all activities of daily living (ADL's). Review of the Plan of Care dated 05/03/22 revealed Resident #30 had alteration in cardiac status related to cerebral vascular accident (CVA) with weakness, HTN, hyperlipidemia (HLD), and malnutrition. Interventions included administration of medications as ordered. 365799 Page 18 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #30's physician orders for June 2022 revealed an order dated 04/11/22 for 81 milligrams (mg) of chewable aspirin to be administered daily for stroke prophylaxis. Observation on 06/13/22 at 10:45 AM of Resident #30 revealed a pill on Resident #30's over the bed table. The table was located on the right side of Resident #30's bed while he was observed lying in bed. There was no licensed medical professional in the room. The resident reported the pill was a baby aspirin that he forgot to take earlier in the morning. Licensed Practical Nurse (LPN) #100 confirmed on 06/13/22 at 11:06 AM there was a pill on the Resident #30's bed side table. Interview on 06/22/22 at 10:59 AM with the Director of Nursing (DON) revealed no residents at the facility were permitted to have any medications at bedside. She revealed Resident #66 and Resident #30 did not have self-administration of medications assessment since they were not permitted to self-administer their medications. She also confirmed neither of those residents were permitted to keep medications at bedside. Review of the facility policy titled Medication Storage, undated, revealed medications were to be stored in a safe and secure manner in compliance with corresponding regulations and manufacturers guidelines and only authorized licensed personnel have access to medication. 3. Review of the medical record for the Resident #2 revealed an admission date of 01/02/18. Diagnoses included heart failure, gastrointestinal bleed, diabetes type two, and dementia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #2 was cognitively intact and required total assistance of two staff members bed mobility and transfers. Review of Resident #2's physician orders dated 11/29/21 revealed an order for Simethicone (gas relief) tablet chewable with instructions to administer 40 milligram (mg) by mouth as needed four times per day for gas. Observation on 06/13/22 at 10:04 A.M. revealed Registered Nurse (RN) #108 administered medication to Resident #2. RN #108 then left the room. It was observed Resident #2 had two pills sitting in her medication cup which she had not yet taken. Resident #2 revealed they were gas pills. Interview on 06/13/22 at 10:24 A.M. with RN #108 revealed Resident #2 was given two 80 MG tablet of Simethicone (Gas relief) tablets, which was her morning and afternoon doses. RN #108 revealed Resident #2 had orders for 40 mg tablet four times daily as needed for gas. RN confirmed she left the medications at bedside and did not observe Resident #2 take all of her medications. Interview on 06/22/22 at 10:56 A.M. with the DON revealed no residents had been assessed and approved to self administer medications. The DON confirmed Resident #2 was not approved to self administer medications. Review of facility policy titled Medication Administration and Medication Storage, undated, revealed the facility would administer medication in a safe manner for regulations and safety goals. Pre-pouring of medication was not the recommended standard of practice. The policy revealed medications should be stored in a safe and secure manner. 365799 Page 19 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 facility policy review, the facility failed to obtain labs as ordered by the physician. This affected two (Residents #6 and #16) out of six residents reviewed for routine labs. The facility census was 74. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 03/14/22. Medical diagnoses included unspecified dementia without behavioral disturbance, unspecified mood (affective) disorder, depression, and chronic obstructive pulmonary disease (COPD). Review of the physician orders for March 2022 revealed Resident #6 had an order dated 03/15/22 for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) lab tests to be completed. The order was discontinued on 03/16/22. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #6 had impaired cognition. Review of Resident #6's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2022 revealed the ordered lab (CBC and BMP) was marked as being completed as ordered. Review of Resident #6's progress notes dated from 03/01/22 through the time of the survey revealed no notes were present related to the labs (CBC and BMP) having been completed or the physician having been notified of any results of the labs for Resident #6. Review of the Care Plan dated 03/14/22 revealed Resident #6 was at risk for adverse effects of medication with interventions that included monitoring labs as ordered. There were no lab results found in Resident #6's medical record. Interview on 06/16/22 at 7:34 P.M. with the Director of Nursing (DON) confirmed the lab results (CBC and BMP) for Resident #6 could not be located anywhere in the facility. The DON called the laboratory and the laboratory did not have any record of the labs having been completed for Resident #6 and did not offer any explanation regarding why the labs were not on file. 2. Review of the medical record for Resident #16 revealed an original admission date of 09/19/19 and a readmission date of 02/22/22. Medical diagnoses included type two diabetes mellitus with hyperglycemia, major depressive disorder, chronic kidney disease stage three, and acute and chronic respiratory failure with hypoxia. Review of physician orders for June 2022 revealed Resident #16 had an order dated 04/10/21 for a complete metabolic panel (CMP), liver function, and hemoglobin A1C (lab used to determine average blood glucose levels over the past few months) labs to be completed every six months (180 days) with instructions to notify the physician and document. Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 had moderately impaired 365799 Page 20 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0770 cognition. Level of Harm - Minimal harm or potential for actual harm Review of Resident #16's MARs and TARs for April 2022 revealed the labs were marked as completed on 04/09/22. Residents Affected - Few Review of Resident #16's progress notes dated from 04/01/21 through the time of the survey revealed there were no notes related the the labs (CMP, liver function, and hemoglobin A1C) having been completed, the results of the labs, or notification to the physician regarding the results of the labs. Review of the Care Plan revised 02/28/22 revealed Resident #16 was at risk for adverse side effects to medications with interventions including monitor labs as ordered and report results to physician. There were no lab results found in Resident #16's medical record. Interview on 06/16/22 at 7:34 P.M. with the DON confirmed the lab (CMP, liver function, and hemoglobin A1C) results for Resient #16 could not be located anywhere in the facility. The DON called the laboratory who did not have any record of the labs (CMP, liver function, and hemoglobin A1C) having been completed for Resident #16 and did not offer any explanation regarding why the labs were not on file. Review of the facility policy titled Lab Policy and Procedure, dated 10/10/13, revealed the policy stated, it is the center's policy to communicate the results of lab tests to patients/residents physician in a timely manner. It is the responsibility of the registered nurse or licensed practical nurse to ensure compliance. Procedure included to review lab results from the center's lab vendor, notify physician services with lab results, and physician services must respond within the parameters of the clinical best practice to results received and patient/residents condition. 365799 Page 21 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and facility policy review, the facility failed to appropriately store and date foods in the refrigerator and freezer. Additionally, the facility failed to appropriately perform hand hygiene during preparation of a lunch meal. This had the potential to affect all 74 residents in the facility. The facility did not have any residents on a nothing by mouth (NPO) diet. The facility census was 74. Findings include: 1. During the initial tour of the kitchen on 06/13/22 at 10:00 A.M. with Dietitian #129, the following items were found in the refrigerator and freezer: one package of fresh strawberries with mold on them, one bag of english muffins that were opened without a date, one bag of frozen french fries that had a hole in the bag, exposing the food to the cold air and without a date on it, five separate packages of frozen waffles without a date on them and one of the bags was opened with the food exposed to the cold air, and one package of two frozen pie crusts that was opened without a date on it. Interview on 06/13/22 at 10:15 A.M. with Dietitian #129 confirmed the above findings. Review of the facility policy titled Labeling and Dating Food, dated 08/31/10, revealed the policy stated, it is the center's policy that all food items be properly labeled and dated. Items delivered to the facility will be properly stored and clearly marked with the item name and the delivery date on the original container. Food removed from its original package will be put into a clean, sanitized food service approved container and covered. The new container must be labeled with the name of the food and the original use by date. 2. Observation of the lunch meal tray line on 06/15/22 from 11:53 A.M. to 12:15 P.M., revealed [NAME] #87 washed her hands with soap and water at the sink and donned clean gloves prior to beginning to plate resident meals. With gloved hands, [NAME] #87 opened a plastic bag of hamburger buns, reached into the bag, and grabbed a bun from the bag with her gloved hands. The cook placed the bun on a plate to make a pulled pork sandwich per the menu. [NAME] #87 adjusted her eyeglasses, opened the steamer and grabbed two bowls out of it, placed the bowls on trays, touched the metal cart holding trays with desserts on them, opened a second plastic bag of hamburger buns, and continued to handle hamburger buns served to residents with the same gloves on. [NAME] #87 did not perform any hand hygiene and continued with the same gloves on throughout the duration of the observation. Interview on 06/15/22 at 12:57 P.M. with Dietitian #129 confirmed the above observations during the lunch meal tray line. Review of the facility policy titled Kitchen Handwashing, dated 06/25/18, revealed the policy stated, Handwashing procedures are to be followed at all times. When to wash hands: before beginning a shift, after using the restroom, after coughing, sneezing, using tobacco, eating or drinking, after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks, when switching between working with raw food and working with ready to eat food, before donning gloves for working with food, after taking out the trash, and after engaging in other activities that contaminate the hands. 365799 Page 22 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0880 Provide and implement an infection prevention and control program. 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, observations, review of a resident vaccination status list, and facility policy review, the facility failed to properly apply Personal Protective Equipment (PPE) when caring for a resident in isolation, failed to ensure catheter bag tubing was not touching the ground, and failed to implement appropriate isolation precautions while an isolation resident was smoking with other non-isolation residents. This affected five residents (#29, #43, #62, #222, and #223) and had the potential to affect all 74 residents residing in the facility. The facility census was 74. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #223 revealed an admission date of 06/07/22. Diagnoses included right ankle and foot osteomyelitis and cellulitis. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/13/22, revealed Resident #223 had intact cognition and no evidence of behaviors. Review of the baseline care plan dated 06/07/22 revealed Resident #223 was on contact/droplet precautions due to not being fully vaccinated against covid-19. Review of the progress note dated 06/16/22 at 6:07 P.M. by Registered Nurse (RN) #42 revealed Resident #223 continued contact/droplet isolation precautions. Review of Resident #223's physician orders for June 2022 revealed an order dated 06/10/22 for contact/droplet isolation precautions. The order was discontinued on 06/16/22. Review of the Resident #223's vaccination matrix revealed Resident #223 was not on the matrix. Review of the daily census sheet revealed Resident #223 was vaccinated for COVID-19 but was not up to date. Observation and interview on 06/14/22 at 9:06 A.M. with Licensed Practical Nurse (LPN) #700 revealed she entered Resident #223's room with a surgical mask under her N95 respirator, used her gloved hands to apply the N95 respirator over her surgical mask, and did not change her gloves prior to entering Resident #223's room. LPN #700 confirmed Resident #223 was on droplet/contact isolation precautions but was unsure as to why. Follow up interview on 06/14/22 at 9:38 A.M. with LPN #700 confirmed Resident #223 was on isolation because she was not fully vaccinated against COVID-19. Interview on 06/15/22 at 12:15 P.M. with the Director of Nursing (DON) confirmed gloves should be applied last when applying (donning) personal protective equipment (PPE) and never before applying a mask/respirator. She also confirmed a surgical mask under the N95 respirator would break the seal of the N95 respirator and ultimately make it ineffective. Interview on 06/22/22 at 12:21 P.M. with the DON confirmed Resident #223 was on isolation precautions from her admission through 06/16/22 but the order was placed late on the 10th during a chart audit. 365799 Page 23 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility signage titled Sequence for Donning Personal Protective Equipment (PPE) by the Centers for Disease Control (CDC) revealed a mask or respirator were to be applied, not both. Further review of the signage revealed the respirator was to be applied and the gown and gloves were to be applied as the last step before entering the resident's room. 2. Review of the medical record for Resident #62 revealed an admission date of 04/08/22. Medical diagnoses included unspecified dementia with behavioral disturbance, hydronephrosis (a condition characterized by excess fluid in a kidney due to a back up of urine) with renal and ureteral calculous obstruction, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms (age-associated prostate gland enlargement that can cause urination difficulty). Review of the physician orders dated June 2022 revealed Resident #62 had orders dated 04/08/22 to empty foley drain bag and complete foley care daily on each shift. Additional orders dated 04/11/22 were in place to change foley as needed, change catheter bag every month on the first day of the month, and maintain foley catheter 18 french 10 cc to straight drain two times per day. Review of the admission MDS assessment revealed Resident #62 had moderately impaired cognition. Resident #62 required extensive assistance from one to two staff to complete activities of daily living (ADLs). Resident #62 had an indwelling catheter. Review of the plan of care revised 06/06/22 revealed Resident #62 had a foley catheter due to diagnoses of hydronephrosis and urinary retention. Interventions included change catheter as a closed system as ordered, encourage fluids, foley cather and pericare per order or facility policy, monitor for signs and symptoms of infection, monitor intake and output as indicated, notify the physician and responsible party of concerns, and size 18 french foley catheter as ordered. Observations on 06/13/22 at 1:02 P.M., on 06/14/22 at 12:04 P.M., and on 06/15/22 at 4:00 P.M., revealed Resident #62's catheter bag tubing was laying on the floor underneath the resident's wheelchair. Interview on 06/15/22 at 4:11 P.M. with State Tested Nurse Aide (STNA) #40 confirmed Resident #62's catheter bag tubing was laying on the floor under his wheelchair. STNA #40 stated, it is not supposed to be like that. Review of the facility policy titled Foley Catheter: Catheter Care, dated 09/11/13, revealed the policy stated, it is the center's policy to manage our patients/residents with foley catheters per physician's orders. The policy did not address appropriate placement of the catheter tubing. 3. Review of the medical record for Resident #222 revealed an admission date of 06/10/22. Medical diagnoses included multiple fractures of ribs on the right side, chronic obstructive pulmonary disease, and unspecified dementia without behavioral disturbance. Review of the physician orders dated June 2022 revealed Resident #222 had an order for contact and droplet isolation on every shift dated 06/10/22 and discontinued on 06/19/22. Review of admission MDS assessment dated [DATE] revealed Resident #222 had impaired cognition. Resident #222 required supervision with one staff physical assistance to complete ADLs. Review of the progress notes dated from admission through the time of the survey revealed on 365799 Page 24 of 25 365799 06/30/2022 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0880 Level of Harm - Minimal harm or potential for actual harm 06/11/22 at 4:34 P.M., Resident #222 was alert and oriented but forgetful at times. Resident #222 was a cigarette smoker and needed to be supervised. Review of the baseline care plan dated 06/10/22 revealed Resident #222 was not vaccinated for COVID-19 and was on contact and droplet isolation precautions. Residents Affected - Many Observation on 06/14/22 from 6:59 P.M. to 7:13 P.M. of the outdoor courtyard patio revealed Resident #222 was sitting at a table on the patio with two family members (a son and daughter) and another resident (later identified as Resident #29). The two residents were not distanced at least six feet apart and were smoking cigarettes next to each other. Another resident (later identified as Resident #43) also joined the table and was sitting in her wheelchair next to Resident #222, within six feet, while Resident #222 was smoking. There were not any facility staff observed on the patio monitoring the patio to ensure Resident #222 remained distanced from other residents. Interview on 06/14/22 at 7:13 P.M. with Registered Nurse (RN) #34 confirmed Resident #222 was under droplet isolation precautions due to COVID-19 precautions and was smoking with other residents who were not under any isolation precautions and resided in different areas of the building. RN #34 stated Resident #222's family wanted to go outside with Resident #222 while she smoked. RN #34 stated she educated the resident's family regarding Resident #222 being in isolation and the need to keep Resident #222 distanced from others but you can see that did not happen. RN #34 confirmed there were not any staff present on the patio to ensure Resident #222 stayed distanced from other residents. Interview on 06/15/22 at 10:49 A.M. with the DON confirmed Resident #222 was under droplet isolation precautions due to COVID-19 protocols. The DON confirmed Resident #222 was non-compliant with following isolation protocols on the unit. The DON stated Resident #222 and any other residents who were under isolation precautions should be supervised by staff and sit at a table by themselves while smoking. Review of the resident vaccination status list revealed Residents #222 and Resident #29 were not vaccinated for COVID-19. Both residents declined to be vaccinated. Resident #43 was fully vaccinated and had received a booster vaccine on 10/07/21. Review of the facility policy Transmission Based Precautions: Droplet Precautions, dated 08/04/20, revealed the policy stated, it is the center's policy to utilize droplet precautions for specified patients/residents known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the patient/resident during coughing, sneezing, talking, or the performance of procedures such as suctioning. Additionally, the policy stated, maintain at least six feet of space between the infected patient/resident and other patient/residents and visitors. 365799 Page 25 of 25