Health inspection·February 22, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review, observations, and staff and resident interviews, the facility failed to ensure resident rooms and facility corridors, lobby and unit hallways temperatures were between 71 to 81 degrees Fahrenheit. This affected two (Resident #30 and #31) of 25 residents reviewed for physical environment. The facility census was 95. Findings include: 1. Medical record review for Resident #30 revealed an admission dated of 01/28/21. Diagnoses included dementia, chronic atrial fibrillation, and chronic systolic heart failure. On 02/14/22 at 7:50 A.M., an interview and observation with Resident #30 revealed his room to be very cold. Resident #30 explained, it was always cold. The maintenance man has come in numerous times, but it was not fixed. The heater was blowing cold air. The heater dials were set on heat and at the highest temperature. On 02/15/22 at 9:15 A.M., an observation of Resident #30 siting in dining area drinking coffee. He said, his room was too cold to enjoy drinking his coffee. Observation of his room revealed it to be cold and the heater was blowing cold air. The heater dials were set on heat and at the highest temperature. On 02/16/22 at 7:45 A.M., a tour of Resident #30's room with Unit Manager #60 verified the heater was not working. When touching the grill part of the unit, the pieces fell off the unit and it was blowing cold air. The heater dials were set on heat and at the highest temperature. On 02/17/22 at 1:00 P.M., an interview with the Maintenance Staff #28 revealed he was not aware of Resident #30's heater was not working until today. He stated, Resident #30 frequently messes with his heater, and it does work. You have to give the heater at least seven to eight minutes to heat up and then it will blow warm heat. 2. Medical record review for Resident #31 revealed an admission dated of 12/11/21. Diagnoses included unspecified dementia with behavioral disturbance. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely cognitively impaired. Observation and interview with Resident #31 on 02/14/22 at 11:37 A.M. revealed he was lying in bed with a t-shirt, shirt over that and a jacket on with a sheet, and two blankets on him. He said he was cold and the heat wasn't working correctly and he stated I want to get warmer. The thermostat read Page 1 of 8 365839 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0584 86 degrees F and there was cold air coming out the top of the heating and air conditioning unit. Level of Harm - Minimal harm or potential for actual harm Observation and interview with Maintenance Assistant (MA) #23 on 02/14/22 at 11:43 A.M. confirmed the heating unit was set on 86 degrees F with cold air blowing out of the top. He asked the resident what he would like the temperature to be set at and the resident said 80 degrees F. The MA said he couldn't have it set at 80 degrees F because it was too high for the resident and said he would set it at 74 degrees F and when the surveyor asked what the regulation was for the temperature setting the MA replied he would set the thermostat at 75 degrees F. There was a request two times to check the temperature of the room, but the MA avoided the question and didn't check the temperature of the room. Residents Affected - Few 3. Subsequent observations on 02/14/22 at 8:30 A.M. revealed the corridor going into the Program Unit revealed the hall thermostat was at 63 degrees Fahrenheit (F). Observation on 02/14/22 at 9:04 A.M. revealed the Rehabilitation Unit 100 hall thermostat read 67 degrees F. Observation on 02/15/22 at 9:20 A.M., the corridor going into the Program unit revealed the hall thermostat was at 62 degrees F. Observation on 02/16/22 in the skilled unit, the thermostat closest to room [ROOM NUMBER] read 68 degrees F. This was confirmed by Housekeeper #9. 365839 Page 2 of 8 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, review of the resident council minutes, and policy review, the facility failed to ensure activities were provided for cognitively impaired residents and provided according to the activity calendar. This affected two (#36 and #41) of four residents reviewed for activities. The facility census was 95. Residents Affected - Few Findings include: 1. Medical record review for Resident #36 revealed an admission date of 08/29/16. Diagnoses included unspecified dementia with behavioral disturbances, diabetes mellitus, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/03/22, revealed Resident #36 was severely cognitively impaired. Functional status was total dependence for bed mobility, extensive assistance for transfers and toilet use and she was supervision for eating. Review of the activities care plan, dated 01/14/22, revealed Resident #36 enjoyed music/entertainment, arts/crafts, movies, television, spirituals, children, dolls, and stuffed animals. She was available for group but her participation level was minimal. Interventions included to invite, encourage, and assist to groups of interest. Review of the activity participation from 12/01/31 through 02/15/22 revealed out of 78 opportunities, there were 45 activities provided to Resident #36. There wasn't any 1:1 activities provided to Resident #36. Review of the activity calendar revealed on 02/14/22 at 10:30 A.M. was Price is Right, and at 11:30 A.M. was Nostalgia. Further review of the calendar on 02/15/22 revealed Penny Ante was at 1:40 P.M. Observations were made on 02/14/22 at 10:25 A.M. to 10:33 A.M. revealed Activity Aide (AA) #19 did not ask anyone to come to the activity for the Price is Right which she turned on the television and rolled the four residents in their wheelchairs and didn't engage those four residents who were seated in the chairs and left them at the television. Observation on 02/14/22 at 11:30 A.M. for Nostalgia has a small group of residents and asking them questions about remembering things. There wasn't any observations of Resident #36 in these groups or that she was invited. Observation was conducted on 02/15/22 at 9:55 A.M. of Resident #36 revealed she was sitting in a wheelchair away from the exercise and was not invited to the exercise activity. Further observation on 02/15/22 at 10:55 A.M. revealed Resident #36 was sitting at a table away from the trivia activity and wasn't invited to join in the trivia. Observation at the same time of the AA #19 revealed she had four people participating in the arm exercises and the same four people participating in trivia, but wasn't reading the questions only asking the four resident's did you know that? AA #19 didn't invite anyone else to the trivia activity. Observations on 02/15/22 at 1:40 P.M. revealed AA #19 was feeding a resident and the Penny Ante 365839 Page 3 of 8 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0679 activity wasn't provided. Level of Harm - Minimal harm or potential for actual harm Interview with AA #16 on 02/15/22 at 1:58 P.M. confirmed mainly the residents she knew would participate in the activity she would invite. She said she had to assist with feeding a resident on 02/15/22 at 1:40 P.M. and wasn't able to have the Penny Ante activity. She confirmed the activity participation logs were blank on the above mentioned days for Resident #36. Residents Affected - Few 2. Medical record review for Resident #41 revealed an admission date of 11/19/19. Diagnoses included non-traumatic brain dysfunction and unspecified dementia without behavior disturbances. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. Review of the care plan dated 01/17/22 revealed Resident #41 enjoyed music/entertainment, arts/crafts, movies, television, and especially spiritual music. She was available for group but her participation level was minimal. Interventions included to invite, encourage, and assist to groups of interest. Review of the activity participation from 12/01/31 through 02/15/22 revealed out of 78 opportunities, there were 28 activities provided to Resident #41. There wasn't any 1:1 activities provided for the resident. Review of the activity calendar revealed on 02/14/22 at 10:30 A.M. was Price is Right, and at 11:30 A.M. was Nostalgia. Further review of the calendar on 02/15/22 revealed Penny Ante was at 1:40 P.M. Observations were made on 02/14/22 at 10:25 A.M. to 10:33 A.M. revealed Activity Aide (AA) #19 did not ask anyone to come to the activity for the Price is Right which she turned on the television and rolled the four residents in their wheelchairs and didn't engage those four residents who were seated in the chairs and left them at the television. Observation on 02/14/22 at 11:30 A.M. for Nostalgia had a small group of residents and asking them questions about remembering things. There wasn't any observations of Resident #41 in these groups or that she was invited. Interview with Resident #41 on 02/14/22 at 11:50 A.M. revealed she enjoyed participating in activities, but the staff don't invite her to come to them. Observation was conducted on 02/15/22 at 9:55 A.M. of Resident #41 revealed she was sitting in a Broda chair away from the exercise and was not invited to the exercise activity. Further observation on 02/15/22 at 10:55 A.M. revealed Resident #41 was sitting at a table away from the trivia activity and wasn't invited to join in the trivia. Observation at the same time of AA #19 revealed she had four people participating in the arm exercises and the same four people participating in trivia, but wasn't reading the questions only asking the four resident's did you know that? AA #19 didn't invite anyone else to the trivia activity. Observations on 02/15/22 at 1:40 P.M. revealed AA #19 was feeding a resident and the Penny Ante activity wasn't provided. 365839 Page 4 of 8 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0679 Level of Harm - Minimal harm or potential for actual harm Interview with AA #16 on 02/15/22 at 1:58 P.M. confirmed mainly the residents she knew would participate in the activity she would invite. She said she had to assist with feeding a resident on 02/15/22 at 1:40 P.M. and wasn't able to have the Penny Ante activity. She confirmed the activity participation logs were blank on the above mentioned days for Resident #41. She confirmed she didn't engage the residents in the above mentioned activities. Residents Affected - Few Review of the Resident Council Minutes dated 03/09/21 and 04/13/21 revealed there was a request for more activities. Review of the facility's policy titled Resident Activities, dated 10/01/18, revealed residents would be encouraged to attend and provided staff assistance as necessary. 365839 Page 5 of 8 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, policy review, and review of the Centers for Disease Control (CDC) guidance and COVID-19 Data Tracker, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 95 residents residing in the facility. Residents Affected - Many Findings included: As of 02/14/22, the facility was in outbreak for COVID-19 infection when one employee tested positive for the virus and had taken care of six residents. 1. Observation on 02/15/22 at 4:10 P.M. revealed Housekeeping Supervisor (HS) #25 and Receptionist #67 had on masks that had ear loop straps and the masks had gaps out of the sides of the cheeks. These masks had N-95 printed on them, but no number or National Institute for Occupational Safety and Health (NIOSH) approved. Interviews at the same time with HS #25 and Receptionist #67 verified they were not wearing the masks the facility had provided them which was an N-95 that had the straps that went on top of the head and around the neck. They confirmed there masks did not fit snuggly. 2. Observation and interview with State Tested Nursing Aide (STNA) #12 on 02/16/22 at 7:12 A.M. revealed he walked out from the break room through the corridor and to the main lobby to the receptionist desk with two employees standing at the receptionist desk and didn't have a mask or eye wear on his face. Interview with STNA #12 stated he had come into the facility through the front door and went down the corridor to the break room and punched in and left the break room and down the corridor to the reception area and got his mask. He said he wanted to punch in before he put his mask on his face. 3. Observation and interview with Dietary Aide (DA) #61 on 02/16/22 at 10:20 A.M. revealed he went over to the program unit and got a big cart of empty breakfast trays and took them from the program unit down a long hall way to the kitchen. He had a N-95 mask on but it was bunched up above his chin and his nose with gaps on the sides of the mask. He confirmed his mask wasn't the one provided by the facility and confirmed it was not fitting snuggly over his chin and nose. 4. Observation and interview with Neurologist Physician #500 on 02/16/21 at 12:31 P.M. revealed he was seeing residents on the program unit and had a mask labeled N-95 with ear loops. The straps were taken down below the ears along the sides of his face and connected to a green strap on both sides of the back of the neck. He confirmed he wasn't wearing a mask that had straps on the top of his head and around his neck. 5. Observation on 02/17/22 at 9:48 A.M. on the Program Unit of Hospice Representative #80 talking with a resident. The Hospice Representative was wearing surgical scrubs with a surgical mask with no eye coverage. The Hospice Representative stated she was not informed the facility was in outbreak status for COVID-19. She stated she was signed in and temperature was checked at the front desk and had not been informed. She stated she had finished up and was ready to leave the facility. Interview on 02/17/22 at 9:52 A.M. with the Administration Assistant #49 stated she had not informed visitors that the facility was in outbreak status. She stated the staff and resident families were notified by Robo-call. 365839 Page 6 of 8 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 02/17/22 at 9:56 A.M. with the Director of Nursing (DON) #16 stated signage to inform of COVID-19 outbreak status was posted on the front door on 02/17/22 at approximately 8:45 A.M. Review of the Centers for Disease Control and Prevention (CDC) titled Counterfeit Respirators/Misrepresentation of NIOSH-approval, undated, revealed signs that a respirator may be counterfeit: No markings at all on the filtering facepiece respirator, no approval number on filtering facepiece respirator or headband, no NIOSH markings, NIOSH spelled incorrectly, and/or filtering facepiece respirator has ear loops instead of headbands. Review of the CDC guidance titled Respirator On/Respirator Off, dated 06/09/20, found at www.cdc.gov/Coronavirus/2019-ncov/downloads/hcp/fs-respirator-on-off.pdf, revealed the top strap of an N-95 respirator should go over and rest at the top back of the head and the bottom strap is positioned around the neck and below the ears, nothing should come between the face and the respirator, and do not wear a respirator that does not have a proper seal. Review of an online resource from CDC titled COVID Data Tracker at https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-ty revealed the county in which the facility was situated was experiencing a substantial spread (orange) of COVID-19 with a positivity rate of 5.74% for the week ending in 02/19/22. Review of an online resource from the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. Review of the facility's policy titled Novel Coronavirus Prevention and Response, dated 11/19/21, revealed the facility will educate staff on proper use of PPE and the application of droplet precautions include eye protection. Staff will wear a well-fitted facemask such as NIOSH-approved N-95 or equivalent higher-level respirator, and eye protection. 365839 Page 7 of 8 365839 02/22/2022 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure call lights in the bathrooms were functioning properly for two of 25 bathrooms reviewed during the annual survey. The facility census was 95. Residents Affected - Few Findings include: Observation of the bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] on 02/14/22 from 9:51 A.M. to 9:53 A.M. revealed the cord for the call light was missing from the wall. Interview with Maintenance Supervisor (MS) #28 on 02/16/22 at 10:37 A.M. confirmed the cords for the call lights in the bathrooms of room [ROOM NUMBER] and room [ROOM NUMBER] were missing. He said he checked the cords for the call lights in the bathrooms, but didn't document it. 365839 Page 8 of 8