Health inspection·February 21, 2019

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 medical record review, observation, resident and staff interviews, and review of a facility handbook, the facility failed to ensure a resident's dignity was maintained when a photograph was posted in the resident's room in view of other residents, staff and visitors. The picture was of the resident's legs and urinary catheter with a personal care directive hand written on the picture. This affected one (#25) of three residents reviewed for dignity. The facility census was 48. Findings include: Review of Resident #25's medical record revealed an admission date of 02/09/18. Medical diagnoses included spinal stenosis, generalized muscle weakness, paraplegia, altered mental status, neuromuscular dysfunction of bladder, fusion of lumbar spine, and hypertension. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required extensive assistance with two plus staff members for bed mobility, dressing, toilet use, and personal hygiene. She was totally dependent for transfers. The resident had an indwelling urinary catheter. Observation and interview with Resident #25 on 02/19/19 at 2:28 P.M., revealed a photograph of the resident on her wall beside her bed. The photograph showed the resident from below the knees down to her feet and she was sitting in her wheelchair. Her catheter tubing was visible. On the photograph, there was handwriting, Please place hips back in chair and in the center!! The resident stated she would prefer the picture was not hanging in an area visible to visitors. Interview with State Tested Nursing Assistant (STNA) #455 on 02/20/19 at 11:20 A.M., verified the resident had a photograph on her wall depicting personal information and her catheter tubing was visible. She stated the photograph was to help the staff to remember how to position her for therapy. Review of the resident handbook under the section titled, Resident Rights & Facility Responsibilities revised on 06/19/18, revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Page 1 of 17 365953 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility failed to ensure advanced directives stored in the hard chart and electronic health record (EHR) were consistent. This affected one (#11) of 16 resident records reviewed for consistency of advanced directives. The census was 48. Findings include: Review of the medical record for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral infarction, muscle weakness, dysphagia, thyroid disorder, major depressive disorder, osteoarthritis, hypercholesterolemia, gout, and disorder of the prostate. Review of Resident #11's hard chart revealed the outside binding of the resident chart was marked with the letter A. Continued review of the hard chart revealed the first page of the chart was the document DNR Identification Form dated 2015, the form identified Resident #11's code status was do not resuscitate (DNR) comfort care (CC) arrest (A). Review of Resident #11's EHR identified the resident's code status was DNR CC. Interview on 02/20/19 at 6:26 P.M. with Licensed Practical Nurse (LPN) #400 revealed the A on the outside binding of the hard chart identified Resident #11's code status was DNR CC A. LPN #400 then reviewed Resident #11's DNR identification form to verify the residents code status. After review of the form, the LPN identified Resident #11's code status was DNR CC A. Continued interview with LPN #400 revealed the EHR for Resident #11 identified the residents code status was DNR CC. Further interview with LPN #400 confirmed the DNR information contained in Resident #11's hard chart and EHR was not consistent. 365953 Page 2 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

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 medical record reviews, resident and staff interviews, review of facility self-reported incidents (SRIs) and review of a facility policy, the facility failed to ensure their policy was implemented when potential resident to resident verbal abuse and potential misappropriation allegations were not reported to the Ohio Department of Health and were not investigated. This affected three (#17, #18 and #25) of three residents reviewed for abuse and misappropriation. The facility census was 48. Residents Affected - Few Findings include: 1. Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Interview with Resident #17 on 02/20/19 at 8:51 A.M., revealed his roommate (Resident #19) was a bully, verbally aggressive to him, and has threatened to hit him. He stated he had told several staff members about this, including Licensed Practical Nurse (LPN) #470. He stated he felt intimidated and threatened. He stated they had been roommates for several months and no one had offered to change his room or do anything about the situation. He stated he avoided his roommate as much as possible but it was hard because they were in the same room. Review of the resident's medical record revealed no documentation regarding the resident and his roommate's interactions. Interview with State Tested Nursing Assistant (STNA) #455 on 02/20/19 at 11:03 A.M., revealed she was aware Resident #17 and his roommate (Resident #19) did not get along. She stated they butt heads and she has heard them argue. She stated they threaten each other. She stated Licensed Social Worker (LSW) #480 was aware and the staff try to keep them separated. She thought they were considering moving one of them to another room. She was not aware of any interventions in place to address the resident's not getting along. Interview with LPN #470 on 02/20/19 at 11:55 A.M., revealed she was aware Resident #17 was not getting along with his roommate (Resident #19). She stated this had been going on for several weeks. She had not witnessed them threatening each other, but STNA #500 reported to her that Resident #17's roommate threatened to hit him. She stated the Administrator and Director of Nursing (DON) were aware of the issues between the residents. Interview with LSW #480 on 02/20/19 at 12:53 P.M., revealed the facility staff had discussed moving the residents to different rooms over the past weekend. She denied knowledge of the resident's threatening each other. She was aware they were not getting along and verified there was nothing documented regarding the resident's interactions and no interventions in place to address the situation. Numerous attempts to reach STNA #500 via telephone on 02/21/19 were unsuccessful. 365953 Page 3 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0607 Review of the facility SRIs revealed there was no SRI regarding Resident #17 or #19 interactions. Level of Harm - Minimal harm or potential for actual harm Interview with the DON and the Administrator on 02/21/19 at 10:52 A.M., revealed they have tried talking with the residents about them not getting along. They discussed moving Resident #19 to a different area to separate them, but have not implemented any interventions to address the situation thus far. The Administrator and DON stated they were not aware of Resident #19 threatening to hit Resident #17. She verified there was no investigation regarding this situation and it had not been reported to the Ohio Department of Health per the facility policy. Residents Affected - Few 2. Review of Resident #18's medical record revealed an admission date of 09/25/18. Medical diagnoses included pneumonia, dysphagia, angina pectoris, obstructive and reflux uropathy, hypertension, and epilepsy. Review of the resident's MDS assessment dated [DATE] revealed a BIMS score of 14, indicating minimal impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Interview with Resident #18 on 02/19/19 at 11:24 A.M., revealed he was missing a cell phone. He stated it had been missing about six weeks. He stated he reported it to everyone on the floor and the laundry workers. He stated no one from administration came to talk to him about it. He stated he had a new cell phone which he purchased for $169.00. Review of the resident's medical record revealed no mention of a missing cell phone. Interview with LPN #400 on 02/19/19 at 3:17 P.M., revealed he was aware Resident #18 was missing a cell phone and it came up missing around three months ago. He stated he told laundry and the DON verbally. He stated the cell phone came up missing when the resident went to the hospital and his daughter could not find his cell phone. Interview with LPN #470 on 02/20/19 at 12:29 P.M., revealed she was aware the resident was missing a cell phone. She stated they looked everywhere for it and were unable to locate it. She stated she did not report this to the administration as she was not working when it came up missing. She stated his daughter got him a new cell phone. Interview with LSW #480 on 02/20/19 at 12:47 P.M., revealed she was aware of the resident's missing cell phone. She stated she did not know if it was found and the facility would replace it if it was not found. She stated she just assumed the issue had been resolved. She did not have any type of investigation documented. She thought it was reported missing in December. She stated she would call the resident's daughter. Further interview with LSW #480 on 02/20/19 at 3:53 P.M., revealed Resident #18's daughter stated the cell phone had not been located and she had replaced it. She stated she did not fill out a missing item report because the resident's daughter was looking for the cell phone. Review of the facility SRIs revealed no SRI was completed regarding Resident #18's missing cell phone. Interview with the DON and Administrator on 02/21/19 at 10:52 A.M., revealed they were not aware of Resident #18's missing cell phone and therefore, had no investigation. She verified it had not been reported to the Ohio Department of Health per the facility policy. 3. Review of Resident #25's medical record revealed an admission date of 02/09/18. Medical 365953 Page 4 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses included spinal stenosis, generalized muscle weakness, paraplegia, altered mental status, neuromuscular dysfunction of bladder, fusion of lumbar spine, and hypertension. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required extensive assistance with two plus staff members for bed mobility, dressing, toilet use, and personal hygiene. She was totally dependent for transfers. Interview with Resident #25 on 02/19/19 at 2:38 P.M. revealed she had lost a cell phone approximately six months ago. She stated housekeeping staff had looked all over for it. She stated it was not found and her daughter bought her a new one. She stated she told quite a few people about her missing cell phone but she could not remember their names. Review of the resident's medical record revealed no mention of a missing cell phone. Interview with STNA #510 on 02/20/19 at 12:39 P.M., revealed she was aware the resident lost a cell phone three to four months ago. She stated they looked everywhere for it and she did not think it was ever found. She stated when an item is lost, the staff tell laundry, put a note in the nursing station about it, and tell housekeepers. She stated they also tell the social worker. Interview with LSW #480 on 02/20/19 at 12:44 P.M., revealed she had no reports of a missing cell phone for Resident #25. Review of the facility SRIs revealed no SRI was completed regarding Resident #25's missing cell phone. Interview with the DON and Administrator on 02/21/19 at 10:52 A.M., revealed they were not aware of Resident #25's missing cell phone and therefore, had no investigation. She verified it had not been reported to the Ohio Department of Health per the facility policy. Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised on 11/23/18, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source. Facility staff should immediately report all such allegation to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. In the case of resident to resident abuse, the facility will refer the matter to the interdisciplinary team to determine the appropriate interventions. 365953 Page 5 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

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 medical record reviews, resident and staff interviews, review of facility self-reported incidents (SRIs) and review of a facility policy, the facility failed to ensure potential resident to resident verbal abuse and potential misappropriation allegations were reported to the Ohio Department of Health and the Administrator. This affected three (Residents #17, #18 and #25) of three residents reviewed for abuse and misappropriation. The facility census was 48. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Interview with Resident #17 on 02/20/19 at 8:51 A.M., revealed his roommate (Resident #19) was a bully, verbally aggressive to him, and has threatened to hit him. He stated he had told several staff members about this, including Licensed Practical Nurse (LPN) #470. He stated he felt intimidated and threatened. He stated they had been roommates for several months and no one had offered to change his room or do anything about the situation. He stated he avoided his roommate as much as possible but it was hard because they were in the same room. Review of the resident's medical record revealed no documentation regarding the resident and his roommate's interactions. Interview with State Tested Nursing Assistant (STNA) #455 on 02/20/19 at 11:03 A.M., revealed she was aware Resident #17 and his roommate (Resident #19) did not get along. She stated they butt heads and she has heard them argue. She stated they threaten each other. She stated Licensed Social Worker (LSW) #480 was aware and the staff try to keep them separated. She thought they were considering moving one of them to another room. She was not aware of any interventions in place to address the resident's not getting along. Interview with LPN #470 on 02/20/19 at 11:55 A.M., revealed she was aware Resident #17 was not getting along with his roommate (Resident #19). She stated this had been going on for several weeks. She had not witnessed them threatening each other, but STNA #500 reported to her that Resident #17's roommate threatened to hit him. She stated the Administrator and Director of Nursing (DON) were aware of the issues between the residents. Interview with LSW #480 on 02/20/19 at 12:53 P.M., revealed the facility staff had discussed moving the residents to different rooms over the past weekend. She denied knowledge of the resident's threatening each other. She was aware they were not getting along and verified there was nothing documented regarding the resident's interactions and no interventions in place to address the situation. 365953 Page 6 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0609 Numerous attempts to reach STNA #500 via telephone on 02/21/19 were unsuccessful. Level of Harm - Minimal harm or potential for actual harm Review of the facility SRIs revealed there was no SRI regarding Resident #17 or #19 interactions. Residents Affected - Few Interview with the DON and the Administrator on 02/21/19 at 10:52 A.M., revealed they have tried talking with the residents about them not getting along. They discussed moving Resident #19 to a different area to separate them, but have not implemented any interventions to address the situation thus far. The Administrator and DON stated they were not aware of Resident #19 threatening to hit Resident #17. She verified there was no investigation regarding this situation and it had not been reported to the Ohio Department of Health per the facility policy. 2. Review of Resident #18's medical record revealed an admission date of 09/25/18. Medical diagnoses included pneumonia, dysphagia, angina pectoris, obstructive and reflux uropathy, hypertension, and epilepsy. Review of the resident's MDS assessment dated [DATE] revealed a BIMS score of 14, indicating minimal impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Interview with Resident #18 on 02/19/19 at 11:24 A.M., revealed he was missing a cell phone. He stated it had been missing about six weeks. He stated he reported it to everyone on the floor and the laundry workers. He stated no one from administration came to talk to him about it. He stated he had a new cell phone which he purchased for $169.00. Review of the resident's medical record revealed no mention of a missing cell phone. Interview with LPN #400 on 02/19/19 at 3:17 P.M., revealed he was aware Resident #18 was missing a cell phone and it came up missing around three months ago. He stated he told laundry and the DON verbally. He stated the cell phone came up missing when the resident went to the hospital and his daughter could not find his cell phone. Interview with LPN #470 on 02/20/19 at 12:29 P.M., revealed she was aware the resident was missing a cell phone. She stated they looked everywhere for it and were unable to locate it. She stated she did not report this to the administration as she was not working when it came up missing. She stated his daughter got him a new cell phone. Interview with LSW #480 on 02/20/19 at 12:47 P.M., revealed she was aware of the resident's missing cell phone. She stated she did not know if it was found and the facility would replace it if it was not found. She stated she just assumed the issue had been resolved. She did not have any type of investigation documented. She thought it was reported missing in December. She stated she would call the resident's daughter. Further interview with LSW #480 on 02/20/19 at 3:53 P.M., revealed Resident #18's daughter stated the cell phone had not been located and she had replaced it. She stated she did not fill out a missing item report because the resident's daughter was looking for the cell phone. Review of the facility SRIs revealed no SRI was completed regarding Resident #18's missing cell phone. Interview with the DON and Administrator on 02/21/19 at 10:52 A.M., revealed they were not aware of Resident #18's missing cell phone and therefore, had no investigation. She verified it had not been reported to the Administrator or the Ohio Department of Health per the facility policy. 365953 Page 7 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident #25's medical record revealed an admission date of 02/09/18. Medical diagnoses included spinal stenosis, generalized muscle weakness, paraplegia, altered mental status, neuromuscular dysfunction of bladder, fusion of lumbar spine, and hypertension. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required extensive assistance with two plus staff members for bed mobility, dressing, toilet use, and personal hygiene. She was totally dependent for transfers. Interview with Resident #25 on 02/19/19 at 2:38 P.M. revealed she had lost a cell phone approximately six months ago. She stated housekeeping staff had looked all over for it. She stated it was not found and her daughter bought her a new one. She stated she told quite a few people about her missing cell phone but she could not remember their names. Review of the resident's medical record revealed no mention of a missing cell phone. Interview with STNA #510 on 02/20/19 at 12:39 P.M., revealed she was aware the resident lost a cell phone three to four months ago. She stated they looked everywhere for it and she did not think it was ever found. She stated when an item is lost, the staff tell laundry, put a note in the nursing station about it, and tell housekeepers. She stated they also tell the social worker. Interview with LSW #480 on 02/20/19 at 12:44 P.M., revealed she had no reports of a missing cell phone for Resident #25. Review of the facility SRIs revealed no SRI was completed regarding Resident #25's missing cell phone. Interview with the DON and Administrator on 02/21/19 at 10:52 A.M., revealed they were not aware of Resident #25's missing cell phone and therefore, had no investigation. She verified it had not been reported to the Administrator or the Ohio Department of Health per the facility policy. Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised on 11/23/18 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source. Facility staff should immediately report all such allegation to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. 365953 Page 8 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

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 medical record review, resident and staff interviews, review of facility self-reported incidents (SRIs) and review of a facility policy, the facility failed to ensure potential resident to resident verbal abuse and potential misappropriation allegations were thoroughly investigated. This affected three (Residents #17, #18 and #25) of three residents reviewed for abuse and misappropriation. The facility census was 48. Residents Affected - Few Findings include: 1. Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Interview with Resident #17 on 02/20/19 at 8:51 A.M., revealed his roommate (Resident #19) was a bully, verbally aggressive to him, and has threatened to hit him. He stated he had told several staff members about this, including Licensed Practical Nurse (LPN) #470. He stated he felt intimidated and threatened. He stated they had been roommates for several months and no one had offered to change his room or do anything about the situation. He stated he avoided his roommate as much as possible but it was hard because they were in the same room. Review of the resident's medical record revealed no documentation regarding the resident and his roommate's interactions. Interview with State Tested Nursing Assistant (STNA) #455 on 02/20/19 at 11:03 A.M., revealed she was aware Resident #17 and his roommate (Resident #19) did not get along. She stated they butt heads and she has heard them argue. She stated they threaten each other. She stated Licensed Social Worker (LSW) #480 was aware and the staff try to keep them separated. She thought they were considering moving one of them to another room. She was not aware of any interventions in place to address the resident's not getting along. Interview with LPN #470 on 02/20/19 at 11:55 A.M., revealed she was aware Resident #17 was not getting along with his roommate (Resident #19). She stated this had been going on for several weeks. She had not witnessed them threatening each other, but STNA #500 reported to her that Resident #17's roommate threatened to hit him. She stated the Administrator and Director of Nursing (DON) were aware of the issues between the residents. Interview with LSW #480 on 02/20/19 at 12:53 P.M., revealed the facility staff had discussed moving the residents to different rooms over the past weekend. She denied knowledge of the resident's threatening each other. She was aware they were not getting along and verified there was nothing documented regarding the resident's interactions and no interventions in place to address the situation. Numerous attempts to reach STNA #500 via telephone on 02/21/19 were unsuccessful. 365953 Page 9 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0610 Review of the facility SRIs revealed there was no SRI regarding Resident #17 or #19 interactions. Level of Harm - Minimal harm or potential for actual harm Interview with the DON and the Administrator on 02/21/19 at 10:52 A.M., revealed they have tried talking with the residents about them not getting along. They discussed moving Resident #19 to a different area to separate them, but have not implemented any interventions to address the situation thus far. The Administrator and DON stated they were not aware of Resident #19 threatening to hit Resident #17. She verified there was no investigation regarding this situation. Residents Affected - Few 2. Review of Resident #18's medical record revealed an admission date of 09/25/18. Medical diagnoses included pneumonia, dysphagia, angina pectoris, obstructive and reflux uropathy, hypertension, and epilepsy. Review of the resident's MDS assessment dated [DATE] revealed a BIMS score of 14, indicating minimal impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Interview with Resident #18 on 02/19/19 at 11:24 A.M., revealed he was missing a cell phone. He stated it had been missing about six weeks. He stated he reported it to everyone on the floor and the laundry workers. He stated no one from administration came to talk to him about it. He stated he had a new cell phone which he purchased for $169.00. Review of the resident's medical record revealed no mention of a missing cell phone. Interview with LPN #400 on 02/19/19 at 3:17 P.M., revealed he was aware Resident #18 was missing a cell phone and it came up missing around three months ago. He stated he told laundry and the DON verbally. He stated the cell phone came up missing when the resident went to the hospital and his daughter could not find his cell phone. Interview with LPN #470 on 02/20/19 at 12:29 P.M., revealed she was aware the resident was missing a cell phone. She stated they looked everywhere for it and were unable to locate it. She stated she did not report this to the administration as she was not working when it came up missing. She stated his daughter got him a new cell phone. Interview with LSW #480 on 02/20/19 at 12:47 P.M., revealed she was aware of the resident's missing cell phone. She stated she did not know if it was found and the facility would replace it if it was not found. She stated she just assumed the issue had been resolved. She did not have any type of investigation documented. She thought it was reported missing in December. She stated she would call the resident's daughter. Further interview with LSW #480 on 02/20/19 at 3:53 P.M., revealed Resident #18's daughter stated the cell phone had not been located and she had replaced it. She stated she did not fill out a missing item report because the resident's daughter was looking for the cell phone. Review of the facility SRIs revealed no SRI was completed regarding Resident #18's missing cell phone. Interview with the DON and Administrator on 02/21/19 at 10:52 A.M., revealed they were not aware of Resident #18's missing cell phone and therefore, had no investigation. 3. Review of Resident #25's medical record revealed an admission date of 02/09/18. Medical diagnoses included spinal stenosis, generalized muscle weakness, paraplegia, altered mental status, neuromuscular dysfunction of bladder, fusion of lumbar spine, and hypertension. Review of the resident's 365953 Page 10 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required extensive assistance with two plus staff members for bed mobility, dressing, toilet use, and personal hygiene. She was totally dependent for transfers. Interview with Resident #25 on 02/19/19 at 2:38 P.M., revealed she had lost a cell phone approximately six months ago. She stated housekeeping staff had looked all over for it. She stated it was not found and her daughter bought her a new one. She stated she told quite a few people about her missing cell phone but she could not remember their names. Review of the resident's medical record revealed no mention of a missing cell phone. Interview with STNA #510 on 02/20/19 at 12:39 P.M., revealed she was aware the resident lost a cell phone three to four months ago. She stated they looked everywhere for it and she did not think it was ever found. She stated when an item is lost, the staff tell laundry, put a note in the nursing station about it, and tell housekeepers. She stated they also tell the social worker. Interview with LSW #480 on 02/20/19 at 12:44 P.M., revealed she had no reports of a missing cell phone for Resident #25. Review of the facility SRIs revealed no SRI was completed regarding Resident #25's missing cell phone. Interview with the DON and Administrator on 02/21/19 at 10:52 A.M., revealed they were not aware of Resident #25's missing cell phone and therefore, had no investigation. Review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised on 11/23/18 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source. Facility staff should immediately report all such allegation to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. 365953 Page 11 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

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 observation, medical record review, and resident and staff interview, the facility failed to ensure a dependent resident received bathing per his bathing schedule. This affected one (#17) of one residents reviewed for choices. The facility identified all 48 residents as requiring assistance for bathing. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. He required physical help in part of bathing with one staff assist. Interview and observation of Resident #17 on 02/20/19 at 9:00 A.M., revealed he received showers very infrequently. He stated he would like to have a shower twice weekly but that does not occur. He stated the staff help him wash up but he would like to not feel like a pigsty. The resident was noted to have dandruff on his shirt and the skin around his ears appeared dry and flaky. Review of the resident's care plan dated 11/22/18 revealed he had a problem of self-care deficit. He had an impaired ability to perform or complete activities of daily living (ADL) for himself, such as feeding, dressing, bathing, toileting related to a cerebrovascular accident. His goal was to achieve/maintain his highest level of physical functioning with ADLs. Interventions included assisting him as needed to complete ADLs and encourage independence. Interview with State Tested Nursing Assistant #455 on 02/20/19 at 11:03 A.M., revealed the resident receives bed baths as he cannot get his legs wet. She stated he should get washed up daily and a full bed bath twice weekly. Interview with Licensed Practical Nurse #70 on 02/20/19 at 11:55 A.M. revealed the resident was able to take a shower. She stated he was scheduled for showers on second shift on Tuesdays and Saturdays. Review of the resident's shower schedule revealed he was scheduled for a shower on Tuesday and Saturday on second shift. Review of the resident's shower documentation for January and February revealed he refused a shower on 01/05/19, 01/15/19, 01/19/19, 01/22/19, 01/29/19, and 02/02/19. There was no documentation of a shower given or refused on 01/01/19, 01/08/19, 01/12/19, 01/26/19, 02/05/19, 02/09/19, 02/12/19, 02/16/19, and 02/19/19. Continued review of the shower documentation revealed the resident had not received a shower in January or February. Interview with the Director of Nursing on 02/20/19 at 4:14 P.M., verified the above shower documentation findings. She observed the resident at the time of interview and verified the resident had dandruff all over his shirt and appeared as if he needed a shower. She stated the facility did not have 365953 Page 12 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0677 a policy regarding resident bathing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365953 Page 13 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medication storage area observations and staff interview, the facility failed to properly label and store medication. This affected two of four medications storage areas observed. The census was 48. Findings include: 1. Observation on 02/21/19 at 11:48 A.M., of the rehabilitation medication cart revealed an opened and undated bottle of the prescribed ophthalmic solution thera tears. Continued observation of the rehabilitation medication cart revealed an opened and undated foil package of prescribed ipratropium/albuterol inhalant solution. Interview on 02/21/19 at 11:50 A.M., with Registered Nurse (RN) #300 verified the bottle of prescribed thera tears and the foil package of prescribed ipratropium/albuterol inhalant solution located in the rehabilitation medication cart was opened and undated. RN #300 confirmed multi-dose medications should be labeled with the date the medication was opened. 2. Observation on 02/21/19 at 12:13 P.M., of the south hall medication revealed an opened and undated bottle of the supplement UTI Stat. Review of the supplement label revealed the open date should be recorded on the bottom of the container, discarded 3 months after opening. Interview on 02/21/19 at 12:15 P.M., with Licensed Practical Nurse (LPN) #350 verified the bottle of UTI Stat was opened and undated. The LPN revealed the supplement was a stock medication, used by many residents. LPN #350 did not know how long the bottle had been opened. 365953 Page 14 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure a resident's laboratory tests were completed as ordered. This affected one (#17) of five residents reviewed for unnecessary medications. The facility census was 48. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's physician's orders revealed an order written on 01/28/19 for a complete blood count (CBC) with differential, complete metabolic profile (CMP), and Depakote level in one week then repeat every four months. Review of the resident's laboratory work revealed he refused the CBC, CMP and Depakote level on 02/05/19. The laboratory paperwork indicated they would try to obtain specimens two more times and then the order would be discontinued due to the resident's wishes. Further review of the resident's medical record revealed no further attempts were made to obtain the resident's laboratory work. Interview with the Director of Nursing on 02/20/19 at 2:49 P.M., verified no further attempts had been made to obtain the resident's laboratory work. She stated the facility does not have a policy concerning obtaining laboratory work. 365953 Page 15 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record review, staff and family interviews, the facility failed to ensure accurate documentation in the medical record for a physician ordered ankle foot orthotic (AFO). This affected one (#11) of one resident reviewed for contractures. The census was 48. Finding include: Review of the medical record for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral infarction, muscle weakness, dysphagia, thyroid disorder, major depressive disorder, osteoarthritis, hypercholesterolemia, gout, and disorder of the prostate. Review of Resident #11's physician order dated 05/25/17, revealed the resident was to have an AFO applied in the A.M. every day. The AFO was to be removed at bedtime. Review of Resident #11's treatment record (TAR) dated 02/19, revealed documentation the AFO was applied and removed per the physician orders. Multiple observations were made of Resident #11 throughout the day on 02/19/19 and 02/20/19 between 9:00 A.M. and 3:30 P.M., there was no observation of the AFO being used/applied. Observation on 02/20/19 at 6:26 P.M., of Resident #11's room revealed there was no AFO located in the resident room. The observation was completed with Licensed Practical Nurse (LPN) #400. Interview on 02/20/19 at 6:06 P.M., with Resident #11's family member revealed the resident did not have an AFO at the facility. The family member revealed the resident used an AFO when the resident was able to walk, but had not used the device in a very long time, probably years. Interview on 02/20/19 at 6:26 P.M., with LPN #400 verified LPN #400 documented the removal of Resident #11's AFO on the TAR on 02/01/19, 02/02/19, 02/05/19, 02/06/19, 02/09/19, 02/10/19, 02/11/19, 02/12/19, 02/14/19, 02/15/19, and 02/1919. The LPN further confirmed for the entire month of 02/19, facility staff were documenting the application and removal of Resident #11's AFO. Continued interview with LPN #400 revealed Resident #400 had not utilized an AFO in a long time. LPN #400 could not identify how long it had been since the resident had worn the AFO. The LPN #400 revealed an AFO was not removed by this LPN at all during the month of 02/19. Interview on 02/21/19 at 8:15 A.M., with the Program Therapy Manager (PTM) #12 revealed Resident #11 was discharged from therapy on 11/21/18. The PTM #12 revealed an AFO was used for the Resident #11 in 2015, when the resident was ambulatory. The PTM verified an AFO had not been used by Resident #11 during the month of 02/19. 365953 Page 16 of 17 365953 02/21/2019 Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's Legionnaires prevention documentation/policy and staff interview, the facility failed to develop and implement a legionella control plan with identified control measures. This had the potential to affect all 48 of 48 residents of the facility. The census was 48. Residents Affected - Many Findings include: Review of a facility document titled Annual Legionnaires Policy Review dated 12/20/18 revealed quality assurance for water management would identify areas, control measures, who measures, and have documentation. Further review revealed this document did not identify control measures, frequency of control measure checks, who was responsible for completing checks, and what corrective action should be taken when control measures were out of desired ranges. Review of the facility's policy tilted Legionnaires Policy dated 09/06/17 revealed the facility will develop a water management program that would establish where control measures should be applied, how to monitor them, and establish ways how to intervene when control limits are not met. Further review revealed the policy did not identify control measures, frequency of control measure checks, who was responsible for completing checks, and what corrective action should be taken when control measures were out of desired ranges. Interview with the Administrator on 02/21/19 at 2:50 P.M., revealed the facility's Legionnaires Policy did not identify control measures, frequency of control measure checks, who was responsible for completing checks, and what corrective action should be taken when control measures were out of desired ranges. 365953 Page 17 of 17