Health inspection·November 16, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframe. This affected two (#40 and #57) of the 19 residents reviewed for timely completion of MDS assessments. The facility census was 85. Findings include: 1) Review of the medical record for Resident #40 revealed an admission date of 08/09/18 with medical diagnoses of Alzheimer's disease, hypertension (HTN), heart failure, and chronic kidney disease stage III. Review of the medical record for Resident #57 revealed an annual MDS with assessment reference date (ARD) of 10/14/23 which indicated Resident #40 had severe cognitive impairment and required set-up to supervision with transfers, bed mobility, toileting and eating. Further review of the MDS revealed a 2) Review of the medical record for Resident #57 revealed an admission date of 09/07/23 with medication diagnoses of congestive heart failure (CHF), HTN, diabetes mellitus, and chronic obstructive pulmonary disease. Review of the medical record for Resident #57 revealed an admission MDS assessment with ARD 09/25/23 which indicated Resident #57 required extensive staff assistance with bed mobility, transfers, dressing and toileting. The MDS indicated Resident #57's cognition was not assessed. Further review of the MDS Interview on 11/15/23 at 8:16 A.M. with Licensed Practical Nurse (LPN) #364 confirmed the annual assessment for Resident #57 and the admission assessment for Resident #77 were not completed timely as per the RAI manual guidelines. LPN #364 confirmed the facility utilized the RAI manual as their policy for MDS coding and completion requirements. Review of the RAI 3.0 manual Chapter 2 pages 2-10 revealed comprehensive MDS assessments include the admission, annual, and significant change in status assessments. Further review of the RAI manual Chapter 2 pages 2-21 revealed an admission MDS assessment is to be completed no later than day 14 from admission date. Review of the RAI manual Chapter 2 pages 2-22 revealed an annual MDS assessment must be completed no later than 14 days after the ARD. Page 1 of 19 365821 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to compete quarterly Minimum Data Set (MDS) assessments within the required time frame. This affected four (#21, #39, #46 and #77) of the 19 residents reviewed for timely completion of MDS assessments. The facility census was 85. Residents Affected - Some Findings included: 1) Review of the medical record for Resident #39 revealed an admission date of 01/26/17 with medical diagnoses of dementia, diabetes mellitus (DM), hypertension (HTN), and hypothyroidism. Review of the medical record for Resident #39 revealed a quarterly MDS assessment with assessment reference date (ARD) of 08/19/23 which indicated Resident #39 was cognitively intact and required supervision with bed mobility, transfers, dressing, and toileting. Review of the quarterly MDS revealed a 2) Review of the medical record for Resident #46 revealed an admission date of 01/18/18 with medical diagnoses of DM, Alzheimer's disease, chronic obstructive pulmonary disease, HTN, and delusional disorder. Review of the medical record for Resident #46 revealed a quarterly MDS assessment with ARD 10/02/23 which indicated Resident #46 had severe cognitive impairment and required partial to moderate staff assistance with toileting, bed mobility, and dressing and was dependent upon staff for bathing. Review of 3) Review of the medical record for Resident #77 revealed an admission date of 05/31/23 with medical diagnoses of schizophrenia, moderate protein calorie malnutrition, HTN. Review of the medical record for Resident #77 revealed a quarterly MDS assessment with ARD 09/07/23 which indicated Resident #77 required extensive staff assistance for bed mobility and toileting and was dependent upon staff for transfers and dressing. Review of the MDS assessment revealed Resident #77's cognition and mood status were not assessed. Further review of the MDS assessment revealed a completed date of 10/06/23. Interview on 11/15/23 at 8:16 A.M. with Licensed Practical Nurse (LPN) #364 confirmed the quarterly assessments for Residents #21, #39, #46, and #77 were not completed timely. LPN #364 confirmed the facility utilized the RAI manual as their policy for MDS assessment coding and completion requirements. 4) Record review of Resident # 21 revealed an admission date 06/09/20 of with diagnosis including but not limited to chronic kidney disease, dysphagia, aphasia, anoxic brain damage, unspecified atrial fibrillation, hypertension, blindness in right eye, type two diabetes, muscle weakness and major depressive disorder. Record review of Resident #21 revealed a quarterly Minimum Data Set (MDS) assessment had been completed on 07/18/23. A quarterly MDS assessment was in progress for ARD date of 10/18/2023 was not completed. 365821 Page 2 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0638 Level of Harm - Minimal harm or potential for actual harm Interview 11/16/23 at 10:18 A.M. with LPN #364 verified Resident #21's quarterly assessment for 10/18/23 had not been completed and was late. Review of the RAI 3.0 manual Chapter 2 pages 2-33 revealed a quarterly MDS assessment must be completed no later than 14 days after the ARD. Residents Affected - Some 365821 Page 3 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to ensure resident interviews were conducted for cognition Brief Interview for Mental Status (BIMS) and for mood 9-Item Patient Health Questionnaire (PHQ-9) as required by RAI manual. This affected two (#57 and #77) of the 19 residents reviewed for Minimum Data Set (MDS) assessment accuracy. The facility census was 85. Residents Affected - Few Findings include: 1) Review of the medical record for Resident #57 revealed an admission date of 09/07/23 with medical diagnoses of congestive heart failure (CHF), hypertension (HTN), diabetes mellitus, and chronic obstructive pulmonary disease. Review of the medical record for Resident #57 revealed an admission MDS assessment with assessment reference date (ARD) 09/25/23 which indicated the facility did not complete resident interviews for BIMS or PHQ-9 and the resident interviews were dashed. Review of the MDS assessment revealed staff interviews were not conducted to determine Resident #57's BIMS or PHQ-9. 2) Review of the medical record for Resident #77 revealed an admission date of 05/31/23 with medical diagnoses of schizophrenia, moderate protein calorie malnutrition, HTN. Review of the medical record for Resident #77 revealed a quarter MDS assessment with ARD 09/07/23 which indicated the facility did not complete resident interviews for BIMS or PHQ-9 and the resident interviews were dashed. Review of the MDS assessment revealed staff interviews were not conducted to determine Resident #77's BIMS or PHQ-9. Interview on 11/15/23 at 10:24 A.M. with Licensed Social Worker (LSW) #424 confirmed she was responsible for completing resident or staff interviews for BIMS and PHQ-9 for each resident at the facility. LSW #424 confirmed the BIMS and PHQ-9 resident interviews were not conducted for Resident #57 or #77 as per the RAI guidelines. LSW #424 stated she did not have time to complete the interviews, so she dashed the responses in the MDS assessments. Review of the RAI 3.0 manual, chapter 3-page C-2 stated the Brief Interview for Mental Status (BIMS) is intended to determine the resident's attention, orientation, and ability to register and recall new information. The manual stated the facility should attempt to conduct the interview with all residents and this interview was to be conducted during the look-back period of the ARD. Further review of the RAI 3.0 manual, Chapter 3-page D 1-2 stated the PHQ-9 interview is intended to obtain resident information related to their mood and the facility should attempt to conduct the interview with all residents. The manual stated the PHQ-9 interview was to be conducted during the look-back period of the ARD. 365821 Page 4 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately fill out a Preadmission Screening and Resident Review (PASARR) for Residents. This affected one (#68) of the five residents reviewed for PASARR. The facility census was 85. Findings include: Resident #68 was admitted to the facility on [DATE] with a diagnosis of acute kidney failure, amnestic disorder due to known physiological condition, metabolic encephalopathy, need for assistance with personal care, muscle weakness, bipolar disorder, alcohol dependence with alcohol-induced persisting dementia, non-pressure chronic ulcer of right heel and midfoot, schizoaffective disorder, and pseudobulbar affect. Review of the Minimal Data Set (MDS) assessment 3.0 dated 09/25/23 revealed Resident #68 had moderate cognitive impairment. Her functional status is listed as totally dependent for transfers, bed mobility, and toileting. The MDS also revealed Resident #68 was incontinent of urine and bowel and assessed with no pressure ulcers. Review of the PASARR dated 05/05/21 for Resident #68, revealed the PASARR was not filled out completely. The PASARR did not have the Resident's diagnosis filled out on the form. Interview with License Social Worker (LSW) #424 on 11/15/23 at 9:10 A.M. confirmed that 05/05/21 was the last PASARR completed on Resident #68. The resident was diagnosed with amnestic disorder on 01/06/22, bipolar disorder on 08/29/23, schizoaffective disorder on 08/03/22, major depressive disorder on 10/28/22, anxiety disorder on 10/27/22, and pseudobulbar effect on 02/07/23. After verifying this information, LSW #424 indicated she filled out a new PASARR and Resident #68 triggered for a PASARR level II to be completed. 365821 Page 5 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the medical record for Resident #87 revealed the resident was admitted to the 07/19/23 with diagnosis of unspecified Protein Calorie Malnutrition, Coronavirus (COVID-19), Extended Spectrum [NAME] Lactamase (ESBL) resistance, muscle weakness, urinary tract infection (UTI), metabolic encephalopathy, hallucinations, alcoholism and klebsiella pneumoniae. Review of the MDS assessment dated [DATE] revealed Resident #87 had moderate cognitive impairment. Her functional status is listed as being totally dependent for transfers, bed mobility, and toileting and the resident was incontinent of urine and bowel. Review of the progress notes dated 11/08/23 at 2:37 P.M. for Resident #87, revealed the final urinalysis results were received and the resident was positive for ESBL. The Physician was notified, and new orders were received for the resident to start Levaquin 250 milligrams (mgs) (antibiotic) twice a day for ten days. The notes indicated Resident #68 continued with hallucinations and a new order was received for the resident to start Depakote (mood stabilizer) 125 mgs every eight hours. Review of the physician orders dated 11/08/23 for Resident #87, revealed the resident was ordered to receive Levaquin 250 mgs twice daily for 10 days for ESBL and Depakote Sprinkles delayed release 125 mgs every eight hours for hallucinations. Review of the care plan dated 07/24/23 for Resident #87 revealed the facility did not have a care plan in place for the resident's diagnosis of ESBL. Review of the RAI 3.0 manual Chapter 4 pages 4 through 8, revealed the comprehensive care plan is an interdisciplinary communication tool that must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Based on medical record reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to develop and implement comprehensive person-centered care plans. This affected three (#31, #77, and #87) of the 19 residents reviewed for comprehensive person-centered care plans. The facility census was 85. Findings included: 1) Review of the medical record for Resident #31 revealed an admission date of 08/18/23 with medical diagnoses of malignant neoplasm of prostate, secondary malignant neoplasm of bone, non-pressure chronic ulcer of left foot, and hypertension (HTN). Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/25/23 for Resident #31, revealed the resident had moderate cognitive impairment and required limited staff assistance with bed mobility, transfers, dressing, and toileting. The MDS assessment did not indicate Resident #31 had any skin issues. Review of a physician's progress noted dated 10/23/23 for Resident #31, revealed the resident was recently hospitalized for a left foot toe amputation. 365821 Page 6 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the comprehensive person-centered care plan dated 08/31/23 for Resident #31, revealed no documentation to support the facility completed a comprehensive person-centered care for the surgical site to his left foot. Interview on 11/16/23 at 10:42 A.M. with Director of Nursing (DON) confirmed Resident #31 had a surgical site to his left foot status post toe amputation. Interview on 11/16/23 at 10:55 A.M. with Licensed Practical Nurse (LPN) #364 confirmed Resident #31 had a surgical site to his left foot and continued to receive treatments to the surgical site. LPN #364 confirmed Resident #31 did not have a person-centered care plan to address the resident's surgical site to the left foot. 2) Review of the medical record for Resident #77 revealed an admission date of 05/31/23 with medical diagnoses of Stage IV pressure (full thickness loss of tissue and skin) pressure ulcer, schizophrenia, moderate protein calorie malnutrition, HTN. Review of the MDS with an ARD of 09/07/23 for Resident #77, revealed the resident required extensive staff assistance with bed mobility, toileting and was dependent upon staff for dressing and transfers. The MDS assessment indicated Resident #77 had a Stage IV pressure ulcer upon admission. Review of the comprehensive person-centered care plan for Resident #77 revealed no documentation to support the facility developed a comprehensive person-centered care plan for the resident's Stage IV pressure ulcer upon admission to the facility. Review of the medical record revealed a comprehensive person-centered care plan, dated 08/21/23, which stated Resident #77 had admitted with a Stage IV pressure ulcer to her coccyx. Interview on 11/16/23 at 10:11 A.M. with LPN #364 confirmed Resident #77's pressure ulcer was present upon admission on [DATE] and that the facility did not develop a comprehensive person-centered care plan for Resident #77's Stage IV pressure ulcer until 08/21/23. 365821 Page 7 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

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 observations, record review, staff and resident interviews, and review of facility policy, the facility failed to provide dependent residents with bathing needs. This affected two (#01 and #37) of the four residents reviewed for activities of daily living (ADLs). The facility census was 85. Residents Affected - Few Finding included: 1) Review of the medical record for Resident #01 revealed the resident had an original admission date of 06/07/22. Diagnoses included, but not limited to, cerebral palsy, Parkinson's disease, chronic obstructive pulmonary disease (COPD), diabetes type 2, morbid obesity, malignant neoplasm of bladder, gastroesophageal reflux, schizoaffective disorder, chronic diastolic heart failure, chronic kidney disease, bipolar disorder, anxiety, gout, and auditory hallucination. Review of the comprehensive plan of care dated 05/30/23 for Resident #01, revealed the resident had an ADL self- care performance deficit related to activity intolerance, fatigue, and impaired balance with an intervention to encourage the resident to participate to the fullest extent possible with each interaction. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 08/29/23 for Resident #01, revealed the resident was cognitively intact, had no behaviors, no rejection of care and no wandering. The resident was assessed to be totally dependent for transfers, toileting, personal hygiene, bathing and required extensive assistance for dressing and bed mobility. Resident #01 was assessed to have an indwelling catheter and was incontinent of bowel. Observation of Resident #01 on 11/13/23 at 9:55 A.M., revealed the resident was seated in an electric wheelchair. The resident's collar of her shirt and extending to the shoulder areas, revealed a large amount white flaking debris covering the resident's shirt. The resident's scalp and throughout the resident's hair had white flaking debris. During interview with Resident #01 at the same time, revealed it had been such a long time since her hair was last washed, the resident could not remember when it was washed. The resident stated she only got a bath once every two weeks or so and was unable to recall when she had been given her last bath because she did not know when her scheduled days were and would like to have one. Review of the ADL tasks recorded by the State Tested Nursing Assistants (STNAs) for Resident #01, revealed a bath/shower was to be given on Monday and Thursday nights. Review of that ADL tasks for the last 30 days revealed a bath/shower was given on 10/19/23, 10/26/23, 11/09/23 and 11/13/23. interview with Resident #01 on 11/14/23 at 2:03 P.M stated she had not been given a shower the night before on 11/13/23 as the ADL task sheet indicated. Interview with Licensed Practical Nurse (LPN) #386 on 11/14/23 at 2:10 P.M. revealed she was unable to locate a paper shower sheet associated with Resident #01 going back to August and was unable to locate any refusals by Resident #01. 2) Review of the medical record for Resident #37, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, major depressive disorder, neuromuscular dysfunction of bladder, bipolar disorder, anemia, foot drop, malignant neoplasm of middle lobe bronchus or lung, type two 365821 Page 8 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0677 diabetes, and COPD. Level of Harm - Minimal harm or potential for actual harm Review of Resident #37 medical record revealed no documentation of a bathing schedule, or a record of when bathing had been provided to the resident since admission on [DATE]. Residents Affected - Few Review of the MDS assessment dated [DATE] for Resident #37, revealed the resident's cognitive skills for daily decision making were impaired with a Brief Interview for Mental Status (BIMS) score of eight. The assessment revealed no behaviors exhibited, no rejection of care and no wandering. The resident was assessed to require substantial or maximal assistance for toileting, hygiene, and showering/ bathing. Observation on 11/13/23 at 9:22 A.M. revealed Resident #37 lying in bed with eyes closed with both feet and legs exposed with a large amount of white flaking areas to both feet and lower legs. There were white flaking chips noted on the exposed mattress throughout the end of the bed where the resident's legs were. Observation and interview on 11/16/23 at 7:30 A.M. with Resident #37, stated he was unaware of when his last bath was but would like some lotion on his legs and feet because they were dry and itchy as he proceeded to pick off a white flaking area on his lower legs. Observation of white flaking chips surrounding the areas where legs were situated on the mattress. Interview on 11/16/23 at 7:33 A.M. with Registered Nurse (RN) #368, verified, both feet and legs had dry flaking skin and RN #368 indicated the resident needed some lotion applied. RN #368 indicated it was unknown when Resident #37 last had a bath. Interview with LPN #364 on 11/16/23 at 2:34 P.M. verified that Resident #37 had not been placed on a shower schedule and no bath/showers had been recorded in the electronic medical records or on any paper shower sheets since the resident's admission on [DATE]. Review of facilities undated shower schedule policy, states, facility has a generalized two shower a week schedule and as requested. The resident care givers will complete a shower sheet with their signatures and when a resident refuses a shower the nurse will be notified, and the nurse will educate the resident on the importance of hygiene and explain risk and benefits and will offer a shower on an alternate day or shift. 365821 Page 9 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to complete weekly skin assessments and the facility failed to complete wound treatments as ordered by the physician for a resident's surgical site. This affected one (#31) of the six residents reviewed for wound care. The facility census was 85. Residents Affected - Few Finding included: Review of the medical record for Resident #31 revealed an admission date of 08/18/23 with medical diagnoses of malignant neoplasm of prostate, secondary malignant neoplasm of bone, non-pressure chronic ulcer of left foot, and hypertension. Review of a skin evaluation assessment dated [DATE] for Resident #31 revealed the resident had skin issues to the toes on the resident's right foot. The medical record revealed no documented evidence that the facility completed any weekly skin assessments after the resident's admission on [DATE]. Review of the admission Minimum Data Set (MDS) for Resident #31 revealed an assessment reference date (ARD) of 08/25/23 which indicated Resident #31 had moderate cognitive impairment and required limited staff assistance with bed mobility, transfers, dressing, and toileting. The assessment revealed Resident #31 had no skin issues. Review of a physician's order dated 10/21/23 for Resident #31, revealed the resident was ordered to have the left foot surgical site cleansed with Vashe wound cleaner, patted dry, have Aquacel dressing (antimicrobial dressings designed to block bacteria from entering a wound) applied over the incision, covered with abdominal (ABD) pad, kerlix applied, and secured with an ace [NAME] every 48 hours for wound care. An additional physician's order dated 11/13/23, revealed to cleanse the left foot surgical site with Vashe wound cleaner, pat dry, apply Aquacel over incision, cover with ABD pad, apply kerlix, and secure with ace [NAME] every 48 hours for wound care. Review of a physician's progress note dated 10/23/23 for Resident #31, revealed the resident was recently hospitalized for left foot toe amputation. Review of the October 2023 treatment administration records (TARs) for Resident #31 revealed no documentation to support the facility completed the treatment as ordered to the resident's left foot surgical site on 10/23/23 and 10/27/23. Review the November 2023 TAR for Resident #31, revealed no documentation to support the facility completed the treatment as ordered to the resident's left foot surgical site on 11/08/23 and 11/10/23. Interview on 11/16/23 at 10:42 A.M. with Director of Nursing (DON) confirmed Resident #31 had a surgical site to the left foot status post toe amputation. The DON confirmed the facility had not conducted weekly skin assessments to monitor the resident skin integrity since admission on [DATE] and failed to monitor the resident's surgical wound. The DON also confirmed the medical record did not contain documentation to support wound care was completed for Resident #31 as ordered on 10/23/23, 10/27/23, 11/08/23, or 11/10/23. The DON indicated Resident #31 was routinely seen by the surgeon for evaluation of the surgical site but was unable to provide any documentation to support the evaluations. 365821 Page 10 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of an undated facility policy titled, Skin Integrity, stated the skin integrity policy had been established to improve, maintain, and monitor all resident's skin integrity. The policy stated residents would have a weekly head to toe skin assessment scheduled for nurses to have an actual visualization of the skin. This deficiency is a recite to the complaint survey completed on 10/03/23. Residents Affected - Few 365821 Page 11 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to complete weekly skin assessments and monitoring of pressure ulcer as per facility policy. This affected one (#77) of the two residents reviewed for pressure ulcers. The facility census was 85. Residents Affected - Few Findings included: Review of the medical record for Resident #77 revealed an admission date of 05/31/23 with medical diagnoses of schizophrenia, moderate protein calorie malnutrition, and hypertension. Review of the weekly skin assessments from 06/02/23 to 06/25/23 for Resident #77, revealed the facility completed the weekly skin assessments. There were no documented weekly skin assessments or monitoring of the resident's Stage IV pressure ulcer to coccyx after 06/25/23 and before the resident was seen by the wound physician on 08/21/23. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/07/23 for Resident #77, revealed the resident was dependent on staff or required extensive staff assistance for activities of daily living (ADLs.) and was assessed as being admitted with a Stage IV pressure ulcer (full thickness loss of tissue and skin). The resident was not assessed for cognition. Review of the wound physician's note dated 08/21/23 for Resident #77, revealed the physician had been consulted to evaluate and manage the resident's wound due to wound vac not staying in place the staff wanted another opinion. The note indicated Resident #77 had an order for wound vac (dated 06/09/23) but due to the location of the wound, the wound vac would not stay in place. The note indicated Resident #77 had Stage IV pressure ulcer to coccyx which measured 4 centimeters (cm) by 3 cm by 0.3 cm with 15 percent eschar (dead tissue) and no indication the wound worsened. The note stated the pressure ulcer was debrided. An additional wound physician note dated 11/13/23 revealed Resident #77's Stage IV pressure ulcer to coccyx measured 3 cm by 3 cm by 0.3 cm and no eschar or slough was present. Interview on 11/15/23 at 11:25 A.M. with Registered Nurse (RN) #501 confirmed Resident #77 had a Stage IV pressure ulcer to coccyx upon admission to the facility on [DATE]. RN #501 confirmed Resident #77's medical record did not have documentation to support the facility completed weekly skin assessments to monitor the Stage IV pressure ulcer to coccyx after 06/25/23. RN #501 stated Resident #77 had been seen weekly by the wound physician since 08/21/23 and confirmed the pressure ulcer had improved. Review of policy titled, Skin Integrity, stated the skin integrity policy had been established to improve, maintain, and monitor all resident's skin integrity. The policy stated residents would have a weekly head to toe skin assessment scheduled for nurses to have an actual visualization of the skin. 365821 Page 12 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure a resident's tube feeding was administered per physician orders. This affected one (#25) of two residents reviewed for tube feeding. The facility census was 85. Findings include: Review of medical record for Resident #25, revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, morbid obesity, unspecified severe protein-calorie malnutrition, major depression, anxiety disorder, osteoarthritis, dysphagia oropharyngeal phase, gastroparesis, cerebral palsy, celiac disease, and gastrostomy. Review of the Minimum Data Set (MDS) assessment 3.0 dated 09/07/23 for Resident #25, revealed a Brief Interview for Mental Status (BIMS) score 15, implying no cognitive impairment. Further review revealed no behaviors exhibited, no rejection of care and no wandering. Resident #25 received 51 percent or more total calories though tube feeding. Review of the physician's orders dated 11/15/23 for Resident #25, revealed the resident was ordered to receive Nutren 2.0 (enteral tube feed nutrition) at 60 milliliters per hour (mL/hr) from 8:00 P.M. to 8:00 A.M via tube feeding pump and water flushes of 300 milliliters (mL) every six hours for hydration. Observation of Resident #25 on 11/16/23 at 7:51 A.M. with Registered Nurse (RN) #368 revealed the resident was receiving Nutren 2.0 via tube feeding pump which was set at 55 mL/hr. Interview at same time with RN #368, verified the pump was set wrong because the order was for 60 mL/hr. Interview with RN #501 on 11/16/23 at 1:55 P.M. indicated the facility had no policy that addressed tube feeding care. 365821 Page 13 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the medical record for Resident #46 revealed an admission date of 01/18/18 with medical diagnoses of diabetes mellitus, Alzheimer's disease, chronic obstructive pulmonary disease, Depression, anxiety, delusional disorder, and pseudobulbar affect. Review of the physician's order dated 09/29/22 for Resident #46, revealed the resident was ordered Risperdal (anti-psychotic medication) 0.5 mgs three times per day for delusions. The physician's order dated 04/04/23 revealed the resident was ordered Risperdal 0.5 mg three times per day for delusional disorder. Review of the most recent AIMS assessment dated [DATE] for Resident #46, indicated there were no identified concerns. Further review of the medical record revealed no documentation to support the facility had completed an AIMS assessment since 03/14/23. Review of the nurse's progress notes from July 2023 through November 2023 for Resident #46, revealed no documentation to support Resident #46 had any behaviors such as tearfulness, signs or symptoms of depression, fearfulness, or delusions as noted in the psychiatry visit notes. Review of a care conference summary note dated 08/08/23 for Resident #46, revealed the staff attempted to contact the husband via phone to attend the care conference, but he did not receive an answer and a message was left. The note stated the Interdisciplinary Team (IDT) discussed Resident #46 becoming tearful more frequently and passive with activities. Review of the psychiatry progress notes dated 09/19/23, 10/03/23, and 10/31/23 for Resident #46, revealed the staff reported Resident #46 had ongoing depression signs and symptoms and occasional tearfulness. The psychiatry progress notes dated 10/31/23 stated the gradual dose reduction (GDRs) for Resident #46's Risperdal have failed due to distressful delusions. The progress noted indicated revealed Resident #46 appeared to be in good spirits with the visit and did not appear acutely fearful or paranoid. Review of the MDS, dated [DATE] for Resident #46, revealed the resident had severe cognitive impairment. The MDS indicated Resident #46 received an antipsychotic, antianxiety, and antidepressant medications and did not have any behaviors. Interview on 11/15/23 at 3:30 P.M. with Registered Nurse (RN) #501, verified resident was on anti-psychotics and was required to have an AIMS assessment quarterly. RN #501 verified the most recent AIMS assessment was completed on 03/14/23. Interview on 11/16/23 at 7:42 A.M. with RN #501 confirmed the medical record for Resident #46 did not contain documentation to support the resident's symptoms of delusions, signs and symptoms of depression, or any behaviors that were reported by staff to the psychiatrist during his visits to the facility on [DATE], 10/03/23, and 10/31/23. RN #501 indicated the GDRs were not being completed due to no reported behaviors by Resident #46. Review of the policy titled, Use of Psychotropic Medication, dated 12/01/18, revealed residents are 365821 Page 14 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not to be given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnoses and documented in the clinical resident, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Resident who received psychotropic medications would receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition and that is documented in the clinical record. The effects of the psychotropic mediations on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis in accordance with nurse assessment and medication monitoring parameters consistent with clinical stands of practice manufacturers specifications on the resident comprehensive plan of care. Any resident who received an antipsychotic medication wound have an AIMS test performed on admission, quarterly, with a significant change in condition, change of anti-psychotic medication, and as needed. Based on record review, staff interviews, and review of facility policy, the facility failed to administer and document as needed (PRN) psychotropic medications for an appropriate indication, failed to implement non-pharmacological interventions prior to administration of PRN psychotropics and failed to timely evaluate and monitor the effectiveness of antipsychotic medications for residents. This affected three (#26, #37 and #46) of the six residents reviewed for unnecessary medication use. The facility census was 85. Finding Include: 1) Record review of Resident #26 revealed an original admission dated of 07/14/2023 with diagnosis's including but not limited to: metabolic encephalopathy, vascular dementia, bipolar disorder, adult failure to thrive, chronic atrial fibrillation, type two diabetes, sleep apnea, hallucination, and orthostatic hypotension. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed no behaviors, rejection of care or wandering. Review of a physician orders dated 08/21/23 for Resident #26 revealed an order for Seroquel 25 (anti-psychotic) milligrams (mgs) twice a day for bipolar. A physician's order dated 09/13/23 revealed an order for Ativan 0.5 mg as needed for anxiety. Review of the October and November 2023 medication administration records (MARs) for Resident #26 revealed PRN Ativan 0.5 mgs was administered on 10/13/23 at 6:30 P.M., 10/17/23 at 8:34 P.M., 10/18/23 at 9:06 P.M., 10/19/23 at 8:00 P.M., 10/29/23 at 8:00 P.M., 10/30/23 at 8:16 P.M, 11/01/23 at 8:30 P.M, 11/04/23 at 8:30 P.M., 11/06/23 at 12:26 P.M. 11/07/23 at 9:50 P.M., 11/09/23 at 3:34 P.M., 11/11/23 at 8:12 P.M., 11/12/23 at 8:10 P.M., 11/13/23 8:22 P.M., and 11/14/23 at 8:00 P.M. Further review of the MARs and treatment administration records (TARs) for Resident #26 revealed no documentation to support the need of the PRN Ativan or any non-pharmacological approaches of redirecting or addressing the resident's behavior when the PRN Ativan was given on the dates. Further review of the medical record for Resident #26 revealed no documented evidence of the staff monitoring the response to or the effects of the psychotropic medications. Additionally, there is no documented evidence the facility completed an Abnormal Involuntary Movement Scale (AIMS) (rating scale that was designed to measure involuntary movements known as tardive dyskinesia which is a disorder that sometimes develops as a side effect of long-term treatment with anti-psychotics) when the resident was ordered Seroquel on 08/21/23. 365821 Page 15 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/16/2023 at 11:05 A.M. with Licensed Practical Nurse (LPN) #364 verified Resident #26 received Seroquel and there was no documentation to support the resident received an AIMS assessment when the resident was ordered Seroquel on 08/21/23. LPN #364 also verified Resident #26 received PRN doses of Ativan with no documentation to support the need for the PRN Ativan or any non-pharmacological approaches of redirecting or addressing the resident's behavior when the PRN Ativan was given on the dates. Interview with the Director of Nursing (DON) on 11/16/23 at 11:10 A.M. verified Resident #26 received psychotropic medications and there was documentation to support the resident was being monitored for any adverse consequences. The DON also verified there had been no AIMS assessment completed on Resident #26. 2) Review of medical record, Resident #37 was admitted on [DATE]. Diagnosis included, but not limited to, major depressive disorder, neuromuscular dysfunction of bladder, bipolar disorder, lung cancer, type two diabetes, and chronic obstructive pulmonary disease (COPD). Review of the admission MDS assessment dated [DATE] for Resident #37 revealed his cognitive skills for daily decision making were impaired with a Brief Interview for Mental Status (BIMS) score of eight. The resident was assessed to have no behaviors exhibited, no rejection of care and no wandering. Review of the physician's order dated 09/21/23 for Resident #37 revealed the resident was ordered Seroquel 25 mg twice a day for behavioral problems and Trazodone (anti-depressant) 50 mg once a day for a sleep aid. Interview on 11/16/2023 at 11:05 A.M. with LPN #364, verified Resident #37 received anti-psychotics and did not have an AIMS assessment when the resident was ordered Seroquel. Interview with the DON on 11/16/2023 at 11:10 A.M., verified Resident #37 received psychotropic medications and there was documentation to support the resident was being monitored for any adverse consequences. 365821 Page 16 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure a Frazier Water Protocol (protocol to allow residents with dysphagia to freely consume thin liquid water with supervision) was followed per resident preference and as physician ordered. This affected one (#21) of one residents reviewed for hydration. The facility census was 85. Findings include: Review of Resident # 21's medical record revealed an admission date of 06/09/2020. Diagnoses included, but not limited to, chronic kidney disease, dysphagia, aphasia, anoxic brain damage, unspecified atrial fibrillation, hypertension, blindness in right eye, type II diabetes, muscle weakness and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 required partial or moderate assistance with eating. Review of a physician order dated 05/10/21 revealed Resident #21 was ordered a Frazier Water Protocol after meals for dysphagia. Additionally, Resident #21 was ordered a regular, pureed texture and nectar consistency diet. Review the comprehensive plan of care, dated 08/10/2020, revealed Resident #21 has a swallowing problem, difficulty with thin liquids, and loss of food or liquids from mouth while eating related to diagnosis of dysphagia, oral phase. Interventions included diet to be followed as prescribed, all staff to be informed of resident's special dietary and safety needs, monitor for shortness of breath, choking, labored respirations, lung congestion, and resident to eat only with supervision. Observations on 11/13/2023 at 10:22 A.M., 11/14/23 at 9:38 A.M., and 11/15/23 at 10:23 A.M. revealed Resident #21 sitting up in bed. On a tray table, within reach of Resident #21, on each of the observations was a large pitcher. Interview on 11/15/23 at 11:49 A.M. with Licensed Practical Nurse (LPN) #391 revealed he was unaware of what the Frazier Water Protocol was, but Resident #21 was provided a pitcher of nectar thickened water to drink as he needed. Interview on 11/15/23 at 12:05 P.M. with State Tested Nurse Aide (STNA) #435, while in Resident #21's room, revealed she received no education on a Frazier Water Protocol for the resident and was unfamiliar with what it was. STNA #435 confirmed Resident #21 received assistance with meals and a pitcher of nectar thickened water was kept bedside for him to drink as needed. Interview on 11/15/2023 at 1:40 P.M. with Dietary Technician (DT) #409 revealed Resident #21 had the Frazier Water Protocol in place to help encourage drinking fluids and the resident's wife wanted him to be able to drink thin water. Additionally, DT #409 confirmed staff should be educated on the Frazier Water Protocol and it is utilized after good oral care is provided and the resident is sitting upright, supervised during drinking, and allowed to drink thin water between meals. Interview on 11/16/23 at 1:55 P.M. with Registered Nurse (RN) #501 revealed the facility was unable 365821 Page 17 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0807 to locate a policy related to the Frazier Water Protocol or for thickened liquids. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365821 Page 18 of 19 365821 11/16/2023 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on Quality Assessment and Assurance (QAA) record review, staff interview, and policy review, the facility failed to ensure QAA meetings were conducted at least quarterly and all required members were in attendance. This had the potential to affect all 85 residents of the facility. The facility census was 85. Residents Affected - Many Findings included: Review of the QAA meeting information revealed the facility conducted a QAA meeting first and second quarter of 2023 with all required members present at the meetings. Review of the Ad hoc QAA meeting attendance sheet, dated 11/08/23, revealed the medical director was not present for the meeting. Further review of the QAA meeting information revealed no documentation to support the facility conducted a QAA meeting in the fourth quarter of 2022. Interview on 11/16/23 at 3:46 P.M. with Registered Nurse (RN) #501 confirmed the Medical Director was not present for the Ad Hoc QAA meeting on 11/08/23. RN #501 also confirmed there was no documentation to support the facility conducted a QAA meeting in the fourth quarter of 2022. Review of the policy titled, Quality Assessment and Assurance, revealed the QAA committee would meet at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary. The policy also stated the committee would consist of a physician designated by the facility. 365821 Page 19 of 19