Health inspection·December 27, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility policy, and record review, the facility failed to ensure residents were provided dignified care related to residents names being visible on the outside of clothing. This affected one (Resident #18) of 24 residents reviewed for dignity. The facility census was 78. Findings include: Review of the medical record for Resident #18 revealed an admission date of 11/19/22. Diagnoses included cerebral infarct and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had significant cognitive impairment and required extensive assistance of one staff for transfers and dressing. Review of the plan of care dated 12/02/22 revealed Resident #18 had a self care deficit with interventions for dressing to have assistance from one staff person. Observation on 12/19/22 at 10:40 A.M. revealed Resident #18 was seen with his name visible on his socks with what looked like tape. Subsequent observation on 12/20/22 at 10:46 A.M. revealed Resident #18 was seen with his name visible on his socks. Interview on 12/20/22 at 10:52 A.M. with Licensed Practical Nurse (LPN) #341 revealed the laundry team stamps names on resident's clothes to make sure it gets back to the correct resident. She verified Resident #18 had his name visible on his socks and revealed all items were labeled, but the resident's name were placed on the inside of the shirt and was typically high up on the socks to be covered with pants. LPN #341 revealed the clothes were labeled with a heating press stamp and not with tape. Review of the facility's policy titled Quality of life, dated 03/2015, revealed the facility would care for residents in a manner and in an environment that promotes and enhances each resident's quality of life. The policy revealed dignity was defined during interactions with residents, staff carry out activities to maintain their self worth. Page 1 of 9 365928 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the facility policy, and record review, the facility failed to ensure a resident had an updated Preadmission Screening and Resident Review (PASARR). This affected one (Resident #4) of two residents reviewed for PASARR. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an admission date of 06/04/12. Diagnoses included borderline personality disorder, post traumatic stress disorder, major depression, and panic disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment. Review of the plan of care dated 12/15/22 revealed Resident #4 was on several psychotropic medications with history of substance use and mental illness with interventions to monitor medications for side effects, and monitor and document behaviors. Interview on 12/20/22 at 9:00 A.M. with Social Services (SS) #244, the Administrator and the Director of Nursing (DON) verified the facility has no record of the PASARR being completed for Resident #4. SS #244 revealed a previous staff member completed an audit, but Resident #4's name was not included in the list of resident's without an updated PASARR. They revealed the county agency revealed they did not have a record going back to 2012 as they have gone to electronic records since then. Review of the facility's policy titled Preadmission Screening, dated 03/17/15, revealed the resident would not be admitted unless the state mental health authority had determined, based on a physical and mental evaluation performed by a person other than the state mental agency prior to admission. 365928 Page 2 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

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 in observation, resident and staff interview and record review, the facility failed to ensure a resident's wound was assessed and monitored after admission. The affected one (Resident #184) of one resident reviewed for non-pressure skin impairments. The facility identified nine residents with non-pressure wounds. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #184 revealed an admission date of 12/16/22. Diagnoses included injury of foreign body (bullet), heart disease, type two diabetes mellitus, and hypertension. Review of the admission nursing assessment dated [DATE] revealed Resident #184 had a gun shot wound to the left thigh and redness to the groin. It did not mention significant bruising to the left thigh. There were no details, measurements, or comments left with skin impairment descriptions. Review of the baseline plan of care dated 12/17/22 revealed the plan of care did not include Resident #184's bullet wound or any monitoring or treatment. Review of the progress note dated 12/17/22 revealed Resident #184 had a telehealth visit and had concerns about his leg. There were no details, measurements, or comments left with skin impairment descriptions. The progress note dated 12/20/22 revealed a follow up on Resident #184's small scabbed area from a gun shot wound noted upon admission. The area remained pink dry and scabbed, and surrounded with bruising. No redness or drainage noted with touch. Resident #184 complained of tenderness and the area remained open to air. There were no details, measurements, or comments left with skin impairment descriptions. There were no physician orders to monitor and/or treat the gun shot wound to the left thigh from 12/16/22 to 12/20/22. Review of the physician orders dated 12/21/22 identified orders to monitor scabbed area to left thigh daily for signs of infection with instructions for monitoring daily for 14 days. Observation and interview on 12/19/22 at 11:15 A.M. of Resident #184's wound revealed a bullet wound on left upper thigh. No dressing was in place and Resident #184 stated the dressing was removed from the area when he admitted on [DATE]. State Tested Nursing Aide (STNA) #208 confirmed there was no dressing in place and she would ask the nurse about orders due to wound being wet, with some bloody discharge. Observation and interview on 12/21/22 at 11:20 A.M. with Licensed Practical Nurse (LPN) #375 and Resident #184 revealed Resident #184's wound was scabbed and dry. LPN #375 stated when a resident gets admitted with a wound or skin impairment, the wound should be assessed and documentation should include the type of wound, measurements and a description of the wound. The doctor should be messaged for orders, if orders were not already provided by the referring provider. Interview on 12/21/22 at 1:54 P.M. with LPN #341 revealed she was not told Resident #184's wound had any bloody discharge by staff on 12/19/22. LPN #341 verified she did not review or document what Resident #184's wound looked like. LPN #341 confirmed no treatments were put in place unit 12/21/22 365928 Page 3 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

F 0684 and revealed the order included the wound should be monitored daily and be left open to air due to being scabbed over. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365928 Page 4 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, interviews of staff and residents, and record reviews, the facility failed to ensure residents with limited range of motion (ROM) received the appropriate treatment and services to increase and/or to prevent a further decrease in ROM. This affected two (Residents #4 and #34) of two residents reviewed for positioning and mobility. The facility identified six current residents with a contracture(s). The facility census was 78. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 06/04/12. Diagnoses included hemiplegia and hemiparesis epilepsy, borderline personality disorder, and panic disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment and required extensive assistance of one for transfers. Resident #4 had an impairment of the upper extremity. Review of the physician order dated 11/03/21 to 12/01/21 and a second order dated 11/29/22 to 12/29/22 revealed orders for occupational therapy (OT) for 28 days to reduce hand contracture. Review of the OT evaluation dated 07/05/22 revealed a goal of staff education on range of motion (ROM) on right upper extremity and proper positioning in wheelchair to decrease risk of decline with a note that staff were not consistent with positioning and not performing ROM exercises. The assessment indicated Resident #4 had some right hand contracture with flaccid arm prior but the spouse reported it had gotten worse. Review of the plan of care dated 12/15/22 revealed Resident #4 had no documentation related to a contracture of the upper extremity and ROM exercises were note listed for care. Interview and observation on 12/19/22 at 2:35 P.M. with Resident #4 revealed he denied knowledge of concerns about wrist/hand mobility. Resident #4's left hand was bawled up into a fist and was not able to use it during the observation. Interview on 12/20/22 at 4:33 P.M. with Licensed Practical Nurse (LPN) #226 and Activities Director #300 revealed no knowledge of any care plan or protective barrier related to Resident #4's contracture. LPN #226 denied knowledge of any ROM exercises for staff to complete with Resident #4. Interview on 12/20/22 at 4:45 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #4 had no current care plan with interventions to address Resident #4's contracture and the ROM exercises. The DON stated there was an old care plan had been resolved. Interview on 12/21/22 at 2:45 P.M. with Occupational Therapy (OT) #374 revealed Resident #4 did refuse to wear the splint. OT #374 stated Resident #4 should still have a care plan and be offered ROM exercises or evaluated for a re-assessment to see if he changes his mind or would be agreeable to care. OT #374 revealed a consistent problem of staff not performing ROM exercises. 2. Review of the medical record for Resident #34 revealed an admission date of 10/23/15. Diagnoses 365928 Page 5 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included cerebral infarct, hemiparesis, and type two diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had significant cognitive impairment and was rarely or never understood and required assistance of two staff for mobility. Resident #34 had an upper extremity impairment. Review of the physician order dated 07/04/22 to 08/01/22 revealed an order for Occupational Therapy (OT) evaluation and treat. Resident #34 had a previous order for a resting hand splint to be worn at night in December 2018 but was stopped after three days. Review of the OT evaluation dated 07/04/22 revealed Resident #34's spouse stated Resident #34 had a contracture and it had gotten worse. The therapy assessment also revealed a goal of training staff to complete ROM exercises and reported issues with staff consistency and the staff were not performing ROM exercises. Review of the OT evaluation dated 07/25/22 revealed the discharge recommendation was to train Resident #34's husband to perform ROM exercises. The final assessment also stated progress from the goal of training staff on completing ROM exercises was discontinued. The assessment stated staff continued to be inconsistent and were not performing ROM exercises on 07/18/22 and 07/22/22. Review of the care plan dated 10/04/22 revealed Resident #34 had no mention of a contracture or intervention related to her contracture and no mention of ROM exercises. Interview and observation on 12/19/22 02:30 P.M. with Resident #34 with a contracted right hand and wrist with no brace in place. Resident #34 stated she did not wear a brace and staff do not do ROM exercises with her. Interview on 12/20/22 at 4:33 P.M. with LPN #226 and Activities Director #300 revealed Resident #34 used to have a splint to wear but they thought she had refused it so the order was discontinued. Staff revealed no knowledge of any care plan, protective barrier, or brace related to Resident #34's contracture. LPN #226 revealed no knowledge of ROM exercises that should be completed with Resident #34. Interview on 12/20/22 at 4:45 P.M. with the Administrator and DON verified Resident #34 had no current care plan with interventions to address Resident #34's contracture and the ROM exercises. The DON stated there was an old care plan had been resolved. Interview on 12/21/22 at 2:40 P.M. with Director of Therapy (DOT) #373 revealed therapy made the final recommendation to train the spouse for ROM exercises for Resident #34. The goals regarding training staff on ROM stayed the same throughout the therapy timeframe. Interview on 12/21/22 at 2:45 P.M. with OT #374 revealed Resident #34's husband was educated and trained to perform ROM exercises. OT #374 stated the staff were not consistent with ROM exercise and would not complete due to not having enough time. OT #374 stated the goal of staff being trained to provide ROM was never completed and was eventually discontinued due to staff continuing to be inconsistent with positioning and not performing ROM exercises. OT #374 stated the facility had a consistent problem of staff not performing these exercises so they recommended for Resident #34's husband to be trained so she could get the needed and recommended care. Review of the facility policy titled Range of Motion policy, dated 04/29/16, revealed a resident 365928 Page 6 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with a limited range in motion would receive appropriate services to prevent further decrease in range of motion. Residents would be monitored for decline quarterly. Review of the facility policy titled Comprehensive Care Plan, dated 11/02/16, revealed the facility would develop a comprehensive care plan for each resident with measurable objectives to meet the resident's medical nursing and psychosocial needs. The care plan must include services to be furnished to attain or maintain the resident highest practicable well-being, any services that would otherwise be required but are not provided due to resident refusals. The care pan should meet professional standards of of quality. 365928 Page 7 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observations, review of the facility policy, and staff interview, the facility failed to follow the therapeutic spreadsheet and provide food portions as planned by a registered dietitian. This had to the potential to affect all 78 residents receiving food from the kitchen. The facility census was 78. Findings include: Review of the breakfast menu spreadsheet dated 12/21/22 revealed the breakfast meal consisted of six ounces of hot cereal. Observation on 12/21/22 at 7:30 A.M. revealed Dietary Server #290 on Unit A kitchenette used a four-ounce scoop for all residents who selected hot cereal. Interview on 12/21/22 at 7:45 A.M. with Dietary Server #290 verified she had served four ounces of hot cereal to all residents who selected hot cereal. Dietary Server #290 verified the portion size was to be six ounces as listed on the meal ticket, which was generated by the menu spreadsheet. Observation on 12/21/22 at 7:35 A.M. revealed Dietary Server #320 on Unit C kitchenette used a four-ounce scoop for all residents who selected hot cereal. Interview on 12/21/22 at 7:50 A.M. with Dietary Server #320 verified she had served four ounces of hot cereal to all residents who selected hot cereal. Dietary Server #320 verified the portion size was to be six ounces as listed on the meal ticket, which was generated by the menu spreadsheet. Dietary Server #320 stated she always uses a four-ounce scoop size for the hot cereal. Interview on 12/21/22 A.M. with Dietary Manager #286 verified the diet spreadsheet for hot cereal specified a serving portion of six ounces and should have been served to all residents who selected hot cereal. Review of the facility policy titled Standardization of Portions, dated January 2018, revealed the portions are to be served as specified on the menu spreadsheets. 365928 Page 8 of 9 365928 12/27/2022 Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160

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 observation, review of facility policy, and staff interview, the facility failed to store foods with label and dates and discard expired foods. This had the potential to affect all 78 residents who received food from the kitchen. The facility census was 78. Findings include: 1. Observation on 12/21/22 at 7:25 A.M. of Unit A kitchenette revealed in the reach in refrigerator, there were two containers of unidentifiable foods with no date and no label. Interview on 12/21/22 at 7:25 A.M. with Dietary [NAME] #321 verified the containers should have been labeled and dated. 2. Observation on 12/21/22 at 7:35 A.M. of Unit B kitchenette revealed in the reach in refrigerator, there was a plastic bag labeled bacon dated 12/11/22. Interview on 12/21/22 at 7:35 A.M. with Dietary Aide #290 verified the containers should have been labeled and dated. 3. Observation on 12/21/22 at 7:45 A.M. of Unit C kitchenette revealed in the refrigerator, there were 15 boiled eggs unlabeled and dated 12/01/22 and there was a plastic bag of labeled swiss cheese dated 12/09/22. Interview on 12/21/22 at 7:45 A.M. with Dietary Aide #320 verified the foods were expired and should have been discarded after seven days. Review of the policy titled Storage of Perishable Foods, undated, revealed prepared or leftover foods should be stored labeled, dated and used within three to seven days, or discarded. 365928 Page 9 of 9