Health inspection·March 13, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, self-reported incident (SRI) review, and policy review, the facility failed to protect Resident #24 from being verbally abused by Resident #9. This affected one (Resident #24) out of three residents reviewed for abuse. The facility census was 62. Findings include: Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included history of transient ischemic attack, major depressive disorder, pulmonary embolism, heart failure, dementia without behavioral disturbance, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively impaired. As of 03/13/24, Resident #9 did not have a care plan in place for behaviors towards other residents. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder. Review of the admission Medicare 5-day MDS dated [DATE] revealed Resident #24 had severe cognitive impairment. A nurse note dated 02/26/24 at 11:18 P.M. revealed Resident #9 was verbally abusing Resident #24 by saying all sorts of things. Resident #24 was quiet and did not say anything back. Review of self-reported incident (SRI) #244623 dated 02/27/24 revealed Resident #9 was verbally abusive toward Resident #24. Resident #24 was silent and did not respond back. Review of the facility investigation for SRI #244623 revealed no staff statements, no information detailing where the incident took place and what interventions were put in place. A shift level administration note dated 03/01/24 at 9:00 P.M. revealed Resident #9 was agitated and angry at Resident #24. Resident #24 was trying to enter the room for the night, but Resident #9 used curse words towards Resident #24. The nurse intervened and removed Resident #24 from the room. The nurse was unsuccessful in educating Resident #9 about Resident #24 being permitted in the room. Resident #24 was taken to a different room for the night. A shift level administration note dated 03/02/24 at 6:41 A.M. revealed Resident #9 still appeared irritated and angry. An attempt to return Resident #24 to the room was unsuccessful. Interview on 03/07/24 at 3:39 P.M. the Administrator verified there was no documentation from the incident on 02/26/24 detailing where the incident occurred, how long the incident lasted, and what Page 1 of 10 365933 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff did to ensure Resident #24 was safe. The Administrator verified she was unaware an additional incident that occurred on 03/01/24 and Resident #24 had to be moved to another room for the night due to Resident #9's behavior towards Resident #24. Interview on 03/13/24 at 4:22 P.M. the guardian of Resident #24 revealed they had not been informed of any verbal altercations from Resident #24's roommate. Review of the Abuse policy (revised January 2024) revealed an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Responding immediately to protect the alleged victim and integrity of the investigation. Increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident from the alleged perpetrator. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Reporting/response: The facility will have written procedures that include reporting all alleged violations to the Administrator, state agency, and all required agencies within specified timeframes. Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: analyzing the occurrences to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; defining hours care provision will be changed and/or improved to protect residents receiving services. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00151210. 365933 Page 2 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, self-reported incident (SRI), and policy review, the facility failed to follow the abuse policy when there were allegations of verbal abuse towards Resident #24. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62. Residents Affected - Few Findings include: Review of medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included major depressive disorder, dementia, and anxiety disorder. The quarterly Minimum Data Set, dated [DATE] revealed Resident #9 was cognitively impaired. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder. The admission Medicare 5-day MDS dated [DATE] revealed Resident #24 was cognitively impaired. Review of nurse note dated 02/26/24 at 11:18 P.M. revealed Resident #9 was verbally abusing roommate (Resident #24) by saying all sorts of things. Resident #24 was quiet and did not say anything back. Review of SRI #244623 dated 02/27/24 revealed an allegation of Resident #9 being verbally abusive to Resident #24. Review of the SRI revealed the incident occurred on 02/26/24 at 10:18 P.M. and was reported to the state agency on 02/27/24 at 3:12 P.M. A shift level administration note dated 03/01/24 at 9:00 P.M. revealed Resident #9 was agitated and angry at Resident #24. Resident #24 was trying to enter the room for the night, but Resident #9 used curse words towards Resident #24. The nurse intervened and removed Resident #24 from the room. The nurse was unsuccessful in educating Resident #9 about Resident #24 being permitted in the room. Resident #24 was taken to a different room for the night. A shift level administration note dated 03/02/24 at 6:41 A.M. revealed Resident #9 still appeared irritated and angry. An attempt to return Resident #24 to the room was unsuccessful. Interview on 03/07/24 at 3:39 P.M. the Administrator verified the allegation of abuse occurred on 02/26/24 was not reported until 02/27/24. The Administrator verified a thorough investigation was not completed as evident by no witness, staff, or other resident statements completed as part of the investigation. Additionally, no interventions were put in place and care plans were not updated. The Administrator verified she was unaware an additional incident that occurred on 03/01/24 and Resident #24 had to be moved to another room for the night due to Resident #9's behavior towards Resident #24. Review of the abuse policy (revised January 2024) revealed an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves identifying, correcting and 365933 Page 3 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intervening in situations in which abuse neglect, exploitation, and/or misappropriation of resident property is more likely to occur. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse,sexual abuse, physical abuse, and the deprivation by an individual of goods and services. Possible indicators of abuse include but are not limited to verbal abuse of a resident overheard. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Responding immediately to protect the alleged victim and integrity of the investigation. Increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident from the alleged perpetrator. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Reporting/response: The facility will have written procedures that include reporting all alleged violations to the Administrator, state agency, and all required agencies within specified timeframe's. Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: analyzing the occurrences to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; defining how care provisions will be changed and/or improved to protect residents receiving services. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00151210. 365933 Page 4 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of self-reported incident (SRI), interview, and policy review, the facility failed ensure an allegation of verbal abuse against Resident #24 was reported immediately. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62. Findings include: Review of medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included major depressive disorder, dementia, and anxiety disorder. The quarterly Minimum Data Set, dated [DATE] revealed Resident #9 was cognitively impaired. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder. The admission Medicare 5-day MDS dated [DATE] revealed Resident #24 was cognitively impaired. Review of nurse note dated 02/26/24 at 11:18 P.M. revealed Resident #9 was verbally abusing roommate (Resident #24) by saying all sorts of things. Resident #24 was quiet and did not say anything back. Review of SRI #244623 dated 02/27/24 revealed an allegation of Resident #9 being verbally abusive to Resident #24. Review of the SRI revealed the incident occurred on 02/26/24 at 10:18 P.M. and was reported to the state agency on 02/27/24 at 3:12 P.M. Interview on 03/07/24 at 3:39 P.M. the Administrator verified the allegation of abuse occurred on 02/26/24 was not reported until 02/27/24. Review of Abuse policy revised January 2024 revealed the facility will have written procedures that include reporting all alleged violations to the Administrator, state agency, and all required agencies within specified timeframe's. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00151210. 365933 Page 5 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of self-reported incident (SRI), interview, and policy review, the facility failed to thoroughly investigate an allegation of verbal abuse to Resident #24 and failed to prevent further potential abuse to Resident #24. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62. Residents Affected - Few Findings include: Review of medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included history of transient ischemic attack, major depressive disorder, pulmonary embolism, heart failure, dementia without behavioral disturbance, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively impaired. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder. Review of the admission Medicare 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #24 had severe cognitive impairment. A nurse note dated 02/26/24 at 11:18 P.M. revealed Resident #9 was verbally abusing Resident #24 by saying all sorts of things. Resident #24 was quiet and did not say anything back. Review of self-reported incident (SRI) #244623 dated 02/27/24 revealed there was an allegation of Resident #9 and Resident #24 being verbally abusive towards one another. Resident #9 was verbally abusive toward Resident #24. Resident #24 was silent and did not respond back. Review of the facility investigation for SRI #244623 revealed no staff statements, no information detailing where the incident took place and what interventions were put in place. Interview on 03/07/24 at 3:39 P.M. the Administrator verified a thorough investigation was not completed as evident by no witness, staff, or other resident statements completed as part of the investigation. The Administrator also verified there was no documentation detailing where the incident occurred, how long the incident lasted, and what staff did to ensure Resident #24 was safe. Abuse policy revised (January 2024) revealed an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Responding immediately to protect the alleged victim and integrity of the investigation. Increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident from the alleged perpetrator. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Reporting/response: The facility will have written procedures that include reporting all alleged 365933 Page 6 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0610 Level of Harm - Minimal harm or potential for actual harm violations to the Administrator, state agency, and all required agencies within specified timeframes. Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: analyzing the occurrences to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; defining hours care provision will be changed and/or improved to protect residents receiving services. Residents Affected - Few This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00151210. 365933 Page 7 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

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 record review and interview, the facility failed to provide adequate bathing and hygiene for residents who required staff assistance with activities of daily living including personal hygiene. This affected two (Resident #26 and #71) out of three residents reviewed for bathing and hygiene. Facility census was 62. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses that included dementia, hemiplegia, and dysphagia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively impaired. Resident #26 required substantial to maximal assist for bathing. Review of bathing documentation revealed Resident #26 received a shower and had hair washed on 02/01/24. Interview on 03/11/24 at 1:36 P.M. Regional Director of Clinical Services #103 verified there was no other documentation of Resident #26 being bathed or showered in February and March, 2024. 2. Review of the medical record revealed Resident #71 was admitted on [DATE] and discharged on 03/01/24 with diagnoses that included chronic obstructive pulmonary disease (COPD), epilepsy, dementia, cachexia, and major depressive disorder. A care plan dated 05/11/21 revealed Resident #71 had a behavior problem of declining to shower, bath, or change clothes. Interventions included to explain all procedures to Resident #71 before starting and allow Resident #71 to adjust to changes, and to anticipate and meet Resident #71's needs. A care plan dated 12/25/23 revealed Resident #71 had an activities of daily living (ADL) self-care performance deficit. Interventions include to provide a sponge bath when a full bath or shower could not be tolerated by Resident #71. The quarterly MDS dated [DATE] revealed Resident #71 had mildly impaired cognition. Resident #71 required substantial to maximal assistance with bathing and hygiene. Review of progress notes from 09/01/23 to 03/01/24 revealed no documentation of Resident #71 being bathed, having hair care done, or refusing bathing and hygiene care. A skin monitoring shower review sheet dated 01/22/24 did not have anything marked to identify if Resident #71 was bathed, had hair washed, nails trimmed, or refused. A skin monitoring shower review sheet dated 02/22/24 revealed Resident #71 refused twice to be showered/bathed. Interview on 03/11/24 at 1:36 P.M. Regional Director of Clinical Services #103 verified Resident #71 had not been showered in probably two years. The only shower and bathing documentation available was from 01/22/24 and 02/22/24. This deficiency represents non-compliance investigated under Master Complaint Number OH00151846, Complaint Number OH00151210. 365933 Page 8 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

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 record review and interview, the facility failed to provide treatment to a resident with diagnosed mental disorders. This affected one (Resident #1) out of three residents reviewed for medication administration. Residents Affected - Few Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included pulmonary embolism, schizoaffective disorder, bipolar, and dementia. Review of physician orders revealed Resident #1 was ordered Abilify (antipsychotic) 300 milligram (mg) intramuscularly (IM) on the 28th of each month. Review of the medication administration record (MAR) revealed Resident #1 was administered Abilify 300 mg IM on 10/28/23. A medication note dated 11/28/23 at 4:27 P.M. revealed Abilify 300 mg was reordered and would be administered once the medication was delivered. Review of the MAR for November revealed Resident #1 was not administered Abilify 300 mg on 11/28/23 due to medication not being available. A medication administration note dated 11/29/23 at 5:38 A.M. revealed Abilify 300 mg was not available for administration. A nursing note dated 12/06/23 at 1:21 P.M. revealed Resident #1 returned from an appointment at 1:10 P.M. and Abilify 300 mg was administered IM. A nursing note dated 12/06/23 at 1:54 P.M. revealed the doctor was notified Abilify was not available to be administered to Resident #1 on 11/28/23 as ordered. When Abilify was delivered on 12/06/23, it was administered to Resident #1. A new order was received to administer Abilify on the sixth of each month instead of the 28th. Interview on 03/07/24 at 11:30 A.M. Regional Director of Operations #104 verified Resident #1's Abilify was not administered as ordered on 11/28/23. This deficiency represents non-compliance investigated under Complaint Number OH00151402. 365933 Page 9 of 10 365933 03/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident received appropriate foot care. Residents Affected - Few This affected one (Resident #71) out of three reviewed for foot care. Facility census was 62. Findings include: Review of the closed medical record revealed former Resident #71 was admitted on [DATE] and discharged on 03/01/24 with diagnoses that included chronic obstructive pulmonary disease (COPD), epilepsy, dementia, cachexia, and major depressive disorder. A care plan dated 12/25/23 revealed Resident #71 had an activities of daily living (ADL) self-care performance deficit related to COPD, decreased mobility function, dementia, difficulty in walking, disorder of muscle, nicotine dependence, rheumatoid arthritis, symbolic dysfunction, history insomnia, polyneuropathy. Interventions include check Resident #71's nail length, trim, and clean on bath day and as necessary. Any changes were to be reported to the nurse. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 had mildly impaired cognition, used a wheelchair, and had no behaviors during the review period. The MDS revealed Resident #71 required substantial to maximal assistance with bathing and hygiene. Review of progress notes from 09/01/23 to 03/01/24 revealed no documentation of Resident #71 having toenails trimmed. Review of the weekly skin assessments from 09/05/23 to 03/01/24 revealed no areas of concern. There was no documentation of toenails needing trimmed. A skin monitoring shower review sheet dated 01/22/24 did not have anything marked indicating Resident #71's toenails were trimmed. Interview on 03/11/24 at 2:51 P.M. Regional Director of Operations #104 verified there was no documentation of Resident #71 seeing a podiatrist or having toenails trimmed. This deficiency represents non-compliance investigated under Complaint Number OH00151846. 365933 Page 10 of 10