Health inspection·July 27, 2023

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 observation, interview, and record review, the facility failed to ensure Resident #14's skin was monitored appropriately for bruising or signs of abnormal bleeding related to anticoagulant use. This affected one resident (Resident #14) out of one resident reviewed for non-pressure skin conditions. Residents Affected - Few Findings include: Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, anemia, congestive heart failure, coronary artery disease, dementia, hypertension, and diabetes. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed Resident #14 had a brief interview for mental status (BIMS) score of six, indicating moderate cognitive impairment, and required limited assistance of one person physical assistance for transfers and bed mobility. Review of Resident #14's medication list revealed the resident received Eliquis (blood thinner) 5 milligrams twice a day for treatment of coronary artery disease. Observation on 07/24/23 at 4:10 P.M. revealed Resident #14 had a light purple and yellow faded bruise the size of a 50 cent piece to her left posterior forearm. Interview on 07/24/23 at 4:10 P.M. with Resident #14 revealed she did not recall how she got the bruise but it did not bother her. Review of Resident #14's medical record revealed no evidence Resident 14's bruise was identified or skin was assessed. Interview on 07/26/23 at 9:35 A.M. with Licensed Practical Nurse (LPN) #470 confirmed Resident #14 had a bruise to her left posterior forearm. Interview on 07/26/23 at 4:05 P.M. with Director of Nursing (DON) #467 confirmed facility had not identified Resident #14 had a bruise until interview with LPN #470 at 9:35 A.M. Review of a Skin Care policy dated 11/2018 revealed skin will be observed upon admission and routinely throughout the resident's stay. Page 1 of 9 365980 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #14 and Resident #48 neurological checks were properly completed to assess for injury after falls. This affected two (Resident #14 and #48) of two residents reviewed for head injuries. Findings included: 1. Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, anemia, congestive heart failure, coronary artery disease, dementia, hypertension, and diabetes. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed Resident #14 had a brief interview for mental status (BIMS) score of six, indicating moderate cognitive impairment, and required limited assistance of one person physical assistance for transfers and bed mobility. Review of Fall Assessment from 04/07/23 revealed Resident #14 was at minimal risk for falls. Review of Resident #14's medication list revealed she took Eliquis (blood thinner) 5 milligrams twice a day for treatment of coronary artery disease. Review of nursing notes from 06/04/23 at 10:06 A.M. revealed Resident #14's spouse called for help. When nurse entered the room, Resident #14 was noted to be in supine position on the floor, was assessed with no injuries noted however Resident #14 was complaining of lower back and head pain. Neurological checks were initiated. Review of a fall investigation from 06/04/23 revealed neurological checks were initiated on 06/04/23 at 9:30 A.M. and stopped on 06/04/23 at 7:00 P.M. with no time frame specified by a physician. Interview on 07/26/23 at 4:04 P.M. with Director of Nursing (DON) #467 confirmed neurological checks were not completed for 72 hours per facility policy. 2. Record review revealed Resident #48 admitted to the facility on [DATE] with diagnosis of dementia. Review of an MDS with an ARD of 07/03/23 revealed Resident #48 has a BIMS of three, indicating moderate cognitive impairment, and required extensive assistance of one person assistance for transfers and bed mobility. Review of a nursing note dated 11/15/22 at 9:37 A.M. revealed nurse went to Resident #48's room to find her in supine position on the floor next to the bed holding her forehead. Assessment of forehead revealed a skin tear with minimal bleeding. Review of a fall investigation dated 11/15/22 revealed neurological checks were started on 11/15/23 at 7:15 A.M. and continued until 12 P.M. then one more check was completed at 7:00 P.M. with no time frame specified by a physician. 365980 Page 2 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/26/23 at 4:04 P.M. with DON #467 confirmed neurological checks were not completed for 72 hours per facility policy. Review of the facility's Head Injury policy dated 08/01/22 revealed neurological checks should continue for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 365980 Page 3 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 Resident #69 received medication timely to manage pain. This affected one resident (Resident #69) of one resident reviewed for pain. Residents Affected - Few Findings include: Review of the closed medical record for Resident #69 revealed an original admission date on 10/23/20, a readmission date on 02/03/21, and a discharge date on 05/26/23. Medical diagnoses included pain in left hip, Alzheimer's Disease, dislocation of left hip, fracture of left femur (thigh bone), cognitive communication deficit, anxiety disorder, delusional disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had severely impaired cognition and scored a three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #69 required extensive assistance from one staff to complete Activities of Daily Living (ADLs). Review of the physician orders for April 2023 revealed Resident #69 had the following order: Tramadol Hydrochloride (HCl) 50 milligrams (mg) three times daily at 6:00 A.M., 2:00 P.M., and 10:00 P.M. The pain medication was ordered on 04/18/23 at 4:01 P.M. Review of the Medication Administration Record (MAR) dated April 2023 revealed Resident #69 did not receive any Tramadol until 04/19/23 at 10:00 P.M. (over 24 hours later). Review of a progress note dated 04/18/23 at 4:03 P.M. revealed a certified nurse practitioner (CNP) was in the building and Resident #69 was noted to be moaning and had facial grimacing. The CNP asked Resident #69 if he was in pain and the resident replied, yes. A new order for Tramadol HCL oral tablet 50 mg by mouth three times daily for pain was received. Resident #69's Power Of Attorney (POA) was notified. Interview on 07/26/23 at 12:58 P.M. with the Director of Nursing (DON) confirmed Resident #69 had an order for scheduled pain medication (Tramadol HCl) dated 04/18/23 at 4:01 P.M. but did not receive the medication until 04/19/23 at 10:00 P.M. The DON stated the nurse should have pulled the medication from the emergency medication box if the facility did not receive the medication from the pharmacy the same evening. Review of the facility policy, Pain Management, dated 08/22/22, revealed the policy stated, the facility must ensure that pain management is provided to residents who require such services. 365980 Page 4 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 staff interview, the facility failed to explicitly grant the resident or resident representative the right to rescind Binding Arbitration Agreements within 30 days of signing the agreement. This affected three residents (#17, #19, and #36) of three residents reviewed for Binding Arbitration Agreements. Residents Affected - Few Findings include: 1. Review of medical record for Resident #17 revealed an admission date of 05/02/23. Diagnoses included Alzheimer's disease, depression, cerebral infarction, dysphagia, and dementia. Review of Resident #17's admission Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was significantly cognitively impaired. Review of Resident #17's Voluntary Arbitration Agreement revealed the agreement was signed on 05/02/23 by Resident #17's legal representative. The agreement stated the agreement could be canceled by notifying the Facility in writing. Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be post-marked within fourteen (14) days (rather than the 30 days required) of the date upon which this Agreement was signed. The notice may also be hand delivered to the Administrator within the same fourteen (14) day period, so long as the Administrator of the Facility or designee signs for the receipt of such notice. On 07/26/23 at 10:46 A.M. interview with Admissions Director #468 confirmed the Binding Arbitration Agreement stated the resident or resident's legal representative can cancel the agreement as long as it is in writing and post marked or hand delivered within 14 days, rather than the required 30 days, of signing the agreement. 2. Review of medical record for Resident #19 revealed an admission date of 10/12/22. Diagnoses included Alzheimer's Disease, dysphagia, dementia, anxiety disorder, delusional disorder, major depressive disorder, and bipolar disorder. Resident #19's admission MDS dated [DATE] revealed Resident #19 was severely cognitively impaired. Review of Resident #19's Voluntary Arbitration Agreement revealed the agreement was signed on 10/25/23 by Resident #19's legal representative. The agreement stated the agreement could be canceled by notifying the Facility in writing. Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be post-marked within fourteen (14) days (rather than the 30 days required) of the date upon which this Agreement was signed. The notice may also be hand delivered to the Administrator within the same fourteen (14) day period, so long as the Administrator of the Facility or designee signs for the receipt of such notice. On 07/26/23 at 10:46 A.M. interview with Admissions Director #468 confirmed the Binding Arbitration Agreement stated the resident or resident's legal representative can cancel the agreement as long as it is in writing and post marked or hand delivered within 14 days, rather than the required 30 days, of signing the agreement. 365980 Page 5 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of medical record for Resident #36 revealed an admission date of 05/03/23. Diagnoses included Alzheimer's Disease, dementia, mood disorder, anxiety disorder, and chronic kidney disease stage 3. Resident #36's admission MDS dated [DATE] revealed Resident #36 was significantly cognitively impaired. Review of Resident #36's Voluntary Arbitration Agreement revealed the agreement was signed on 05/03/23 by Resident #36's legal representative. The agreement stated the agreement could be canceled by notifying the Facility in writing. Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be post-marked within fourteen (14) days (rather than the 30 days required) of the date upon which this Agreement was signed. The notice may also be hand delivered to the Administrator within the same fourteen (14) day period, so long as the Administrator of the Facility or designee signs for the receipt of such notice. On 07/26/23 at 10:46 A.M. interview with Admissions Director #468 confirmed the Binding Arbitration Agreement stated the resident or resident's legal representative can cancel the agreement as long as it is in writing and post marked or hand delivered within 14 days, rather than the required 30 days, of signing the agreement. 365980 Page 6 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to properly track infections to identify infectious trends or patterns to prevent transmission. This had the potential to affect all 76 residents in the facility. Residents Affected - Many Findings included: Record review revealed facility's infection control log did not contain a category regarding the type of organism in infections or whether the infection was facility acquired or the resident had the infection upon admission. The facility map for infections for each month did specify type of infection, such as urinary tract infection, skin infection, or respiratory infection but it did not detail which organism was growing in the infection. Interview on 07/27/23 at 1:10 P.M. with Assistant Director of Nursing (ADON) #460 confirmed the facility did not keep information of whether an infection was in house acquired or present upon admission on the log or the facility map. ADON #460 also stated trends in infections were only reviewed once a month during a quality assurance meeting. ADON #460 confirmed the facility does not list which type of organism an infection is growing on the log or the facility map. Review of a policy titled Infection Control and Prevention dated 04/01/22 revealed the infection preventionist of the facility is responsible for knowledge of infectious disease, resident room placement, implementing precautions, staff and resident exposure and surveillance. The policy states a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services in the facility. The infection preventionist should maintain documentation, findings, and any corrective actions the facility should take. 365980 Page 7 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0881 Implement a program that monitors antibiotic use. 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, facility failed to ensure Resident #26 and #324 met the criteria for antibiotic use before antibiotics were administered. This affected two (Resident #26 and #324) of two residents reviewed for antibiotic stewardship. Residents Affected - Few Findings included: 1. Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including hypertension, aphasia, diabetes, dysphagia, anemia, anxiety disorder, and Alzheimer's disease. Review of a Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/22/23 revealed Resident #26 had a brief interview for mental status (BIMS) staff assessment completed showing severe cognitive impairment, bladder assessment revealed Resident #26 is always incontinent of bladder, and requires total dependence of one person assist for toileting. Review of infection control log revealed Resident #26 was treated for a urinary tract infection (UTI) on 03/11/23 with one dose of Ceftriaxone injection 1 gram. Review of nursing notes from 03/11/23 revealed after Resident #26 had a seizure, a certified nurse practitioner gave an order for a urinary analysis with culture and an order to give one gram of Ceftriaxone via intramuscular injection one time. Review of urine analysis results from 03/11/23 revealed no growth after 48 hours. Review of Revised McGreer Criteria for Infection Surveillance Checklist completed on 03/11/23 revealed criteria one and two must be fulfilled for an antibiotic to be administered. Criteria one includes at least on symptom from the list of acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate; fever or leukocytosis and one or more of acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency; or if no fever or leukocytosis, then at least two symptoms from the list of suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked in urgency, and new or marked increase in frequency. Criteria two includes growth of at least one microbiologic criteria. Resident #26 did not met neither criteria one nor criteria two with only new or marked increase in incontinence. Review of infection control log revealed Resident #26 was treated for an upper respiratory infection (URI) on 03/24/23 with five doses of Levaquin 750 milligrams. Review of nursing notes from 03/24/23 revealed Resident #26 received a new order for Levaquin 750 milligrams daily for five days. Resident #26 received a dose on 03/24/23, 03/25/23, 03/26/23, 03/27/23, 03/28/23. Nursing note on 03/27/23 stated chest X-ray results had been received and lungs were clear. Review of chest X-ray obtained on 03/21/23 revealed Resident #26 had no acute issues, but the view was limited so a follow exam was recommended. A second chest X-ray was completed on 03/23/23 revealed Resident #26's lungs are clear with no significant findings. 365980 Page 8 of 9 365980 07/27/2023 Forest Hills Center 2841 East Dublin-Granville Road Columbus, OH 43231

F 0881 Level of Harm - Minimal harm or potential for actual harm Review of Revised McGreer Criteria for Infection Surveillance Checklist completed on 03/26/23 revealed criteria for a URI common cold syndrome or pharyngitis must include at least two criteria from the list of runny nose or sneezing; stuffy nose or nasal congestion; sore throat, hoarseness or difficulty in swallowing; dry cough; or swollen or tender glands in the neck. Resident #26 was marked for only one criteria, stuffy nose or nasal congestion. Residents Affected - Few Interview on 07/27/23 at 10:53 A.M. with Assistant Director of Nursing (ADON) #460 confirmed Resident #26 received one dose of antibiotics for a UTI without meeting McGreer's criteria for infections and with negative urine analysis results. ADON #460 confirmed Resident #26 was treated for a URI with five doses of Levaquin without meeting McGreer's criteria for URI and with two chest X-rays with no findings. 2. Record review revealed Resident #324 admitted to the facility on [DATE] with diagnoses including major depression, hyperlipidemia, diabetes, hypertension, bipolar disorder, dementia, and atrial fibrillation. Review of an MDS from 01/10/23 revealed Resident #324 had a BIMS of 7, required extensive assistance of one person physical assist for toileting, and was frequently incontinent of bladder. Review of the infection control log revealed Resident #324 was treated for a UTI on 01/31/23 with one gram of Ceftriaxone intramuscular injection. Review of nursing notes from 01/31/23 at 2:41 P.M. revealed Resident #324 had blood in his urine and a new order was received for a urine analysis to be completed. An additional nursing note from 01/31/23 at 4:09 P.M. revealed a new order for Ceftriaxone injection one gram intramuscularly once a day for three days. Resident #324 received one dose on 01/31/23, one dose on 02/01/23, and one dose on 02/02/23. Review of urine analysis results from 01/31/23 revealed no indications of a UTI. Review of Revised McGreer Criteria for Infection Surveillance Checklist completed on 03/11/23 revealed criteria one and two must be fulfilled for an antibiotic to be administered. Criteria one includes at least on symptom from the list of acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate; fever or leukocytosis and one or more of acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency; or if no fever or leukocytosis, then at least two symptoms from the list of suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked in urgency, and new or marked increase in frequency. Criteria two includes growth of at least one microbiologic criteria. Resident #324 was marked for gross hematuria and new or marked increase in incontinence for criteria one but did not meet criteria two. Interview on 07/27/23 at 10:53 A.M. with ADON #460 confirmed Resident #324 did not meet McGreer's criteria for infections and he did receive three doses of an antibiotic after having a negative urine analysis. Review of a policy titled Antibiotic Stewardship dated 02/19 revealed the facility should use McGreer criteria as a guide prior to administering an antibiotic. 365980 Page 9 of 9