Health inspection·November 28, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure the medical record was accurate related to a change in condition for a resident. This affected one (Resident #1) of three sampled residents. The census was 91. Findings include: Closed record review for Resident #1 revealed an admission date of 06/06/22. Diagnoses included non-traumatic brain dysfunction, renal failure, diabetes, Alzheimer's, and seizure disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood. She required extensive assistance for bed mobility, transfers, and toilet use. She required supervision for eating. She was always incontinent for bowel and bladder. Review of Resident #1's progress notes dated 09/07/23 at 5:34 P.M. revealed Licensed Practical Nurse (LPN) #99 wrote a new order for Complete Blood Count (CBC), Basic Metabolic Panel (BMP) hemoglobin A1C, Vitamin D, B12, Lipid panel and a chest X-ray for being lethargic. All parties were made aware. Review of the progress notes dated 09/07/23 at 7:38 P.M. documented Resident #1's vital signs were: heart rate 120 beats per minute; blood pressure, 90/46; respirations, 24 breaths per minute and oxygen saturation of 66 percent. Review of the progress notes dated 09/07/23 at 7:55 P.M. revealed Resident #1's oxygen saturation was 60 percent on two liters of oxygen, but not effective. The family was at the bedside and the resident was sent to the hospital for evaluation. There were no other progress notes related to any change in condition for Resident #1 on 09/07/23. During interview on 11/28/23 at 9:34 A.M., LPN #99 stated sometime before 5:34 P.M., a State Tested Nursing Assistant (STNA) came to get her and said Resident #1 wasn't acting like she usually did. LPN #99 went to the room and the family was in the room and the nurse took vital signs, and the pulse oximeter read between 80 and 90 percent, so she placed oxygen on the resident. She stated she had a difficult time getting a good reading because the resident had on fingernail polish and told the family this. She stated the family removed the fingernail polish and the reading was 66 percent. She stated she should have put more detail into the progress notes such as checking the pulse oximeter and the reading was 80 to 90 percent, the fingernail polish on the resident's fingers and not a good Page 1 of 2 365799 365799 11/28/2023 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reading was obtained and the family taking off the polish. She further confirmed the vital signs were put into the record after the resident went to the hospital and the note at 7:55 P.M. was a late entry as well. She stated Resident #1's lungs were not clear, but that was not documented. LPN #1 verified her charting didn't show the picture of what happened with Resident #1 on 09/07/23. Review of policy titled Change in Resident's Condition or Status, dated 04/12/21, revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical /mental condition or status (e.g., assessment, appropriate notifications, interventions, and response). This is an incidental deficiency discovered during the course of this investigation. 365799 Page 2 of 2