Health inspection·March 22, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, policy review and interview, the facility failed to provide adequate accommodations to prevent possible resident exposure to a known pet allergy. This had the potential to affect one (Resident #69) of one resident identified as having a pet allergy. The facility census was 77. Residents Affected - Few Findings include: Medical record review revealed Resident #69 was admitted on [DATE] with diagnoses including epilepsy, macular degeneration, weakness, dizziness and anxiety. The resident record indicated an allergy to cats. Review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact for daily decision-making. On 03/12/24 at 6:10 A.M., interview with Licensed Practical Nurse (LPN) #13 stated the facility has cats and they get on everything. LPN #13 did not know if there were any residents allergic to cats. On 03/12/24 at 6:12 A.M., observation revealed a facility cat was walking in the television/dining area on the 100 Hall. On 03/12/24 at 6:25 A.M., interview with Registered Nurse (RN) #15 stated she was not aware of residents who were allergic to cats but the facility did have cats that roamed freely around the facility. On 03/12/24 at 6:30 A.M., interview with LPN #17 stated the facility-owned cats roam freely throughout the facility and into resident rooms. LPN #17 stated she did not know off-hand of any residents allergic to cats. On 03/12/24 at 6:38 A.M., interview with Resident #69 states she is allergic to cats and does not want the facility cat in her room. Resident #69 did not state the extent of her cat allergy. On 03/13/24 at 12:18 P.M., interview with the Director of Nursing (DON) stated staff was aware of residents with cat allergies and was alerted by a 'cat' magnetic on the door frame of their room. Staff was to keep the cat out of those rooms. On 03/13/24 at 12:25 P.M., observation of Resident #69's room revealed no 'cat' magnetic indicating that the resident was allergic to cats. At the time of the observation, interview with State Tested Page 1 of 8 366001 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse Aide (STNA) #19 stated she had been here for 20 years, cares for Resident #69 routinely and was unaware she was allergic to cats. STNA #19 verified there was no magnet on the door frame of Resident #69's room to indicate she was allergic to cats and stated she would like to know if there were any other residents allergic to cats. On 03/13/24 at 12:28 P.M., observation with the director of nursing (DON) verified Resident #69's door frame did not have a 'cat' magnet indicating the resident was allergic to cats and this was the facility standard of practice so staff knew to shoo the cat away and prevent the cat from entering those rooms. Review of the policy: Pet Service Animals (revised March 2021) revealed Pets/Service/Assistance animals are not permitted in food preparation areas, medication rooms, or resident rooms other than the resident or handler to which the pet/service/assistance animal is approved. Pet/service/assistance animals may be in common areas provided no resident in that common area is allergic or phobic of the animal. Further review of the policy revealed no evidence of how facility staff was to identify residents who were allergic to cats and how they were to be kept out of those resident rooms. This deficiency represents incidental finding of non-compliance investigated under Complaint Number OH00151275. 366001 Page 2 of 8 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review, policy review and interview, the facility failed to initiate fall interventions and complete fall interventions as recommended. This affected three of three residents (Resident #69, #139 and #141) reviewed for falls. The facility census was 77. Findings include: 1. Medical record review revealed Resident #139 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, obstructive uropathy and hypertension. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #139 was severely impaired for daily decision-making, had signs/symptoms of fluctuating inattention and disorganized thinking and required the use of a walker for ambulation. a. Review of the Fall Incident Report dated 01/06/24 revealed Resident #139 was lying on the floor with non-skid footwear in place and his walker beside him. A skin tear was noted to elbow, an abrasion to his left shoulder and he was assisted back to bed. The resident stated he got dizzy and fell. Immediate fall interventions included neurologic checks. Review of Resident #139's Neurological Flow Sheets revealed neuro checks were completed as follows: -On 01/06/24 at 7:45 P.M., 8:00 P.M., 8:15 P.M., 8:30 P.M., 9:00 P.M., 9:30 P.M. and 10:30 P.M -On 01/07/24 at 1:30 A.M., 5:30 A.M., 9:30 A.M., 1:30 P.M. and 5:30 P.M -On 01/08/24 at 1:30 A.M. and 9:30 A.M. Review of the the Fall Risk assessment dated [DATE] revealed Resident #139 was at high risk for falls. b. Review of the Incident Report dated 03/01/24 revealed staff observed Resident #139 ambulating in the hallway when he lost his balance and slid down the wall. Staff was unable to get to the resident before he was on the floor. The resident was oriented to person only and a wanderer. Immediate action taken was to assist the resident to the wheelchair, assess for injury and treatment initiated for a skin tear. Staff reminded Resident #139 to ask for staff assistance to ambulate if not using walker. Review of the Progress Notes dated 03/05/24 revealed the Nurse Practitioner ordered to change Resident #139's indwelling urinary catheter and obtain a urine culture/sensitivity due to a history of recurrent urinary tract infection, having some weakness, increased confusion, complaining of suprapubic tenderness, and indwelling catheter draining very cloudy urine. The urine was obtained on 03/05/24. There was no evidence a fall risk assessment was completed after the resident's fall on 03/01/24. 366001 Page 3 of 8 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 03/13/24 at 1:55 P.M., interview with the Director of Nursing (DON) verified Resident #139 resided on the dementia unit and his cognition was impaired. The DON verified there was no new fall intervention implemented until 03/05/24 after the Interdisciplinary Team met to discuss resident falls. c. Review of the Nurses Note dated 03/10/24 revealed nurse aides were giving report and heard a thud. Upon entering Resident #139's room, he was found sitting on the floor by the bathroom. There was a wheelchair and his walker by where he was found. The resident was assisted to a standing position and back into the wheelchair and neurological (neuro) checks were initiated. Review of Resident #139's Neurological Flow Sheets revealed neuro checks were completed as follows: -On 03/10/24 at 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:15 P.M., 3:45 P.M., 4:45 P.M., 5:45 P.M., 7:29 P.M., and 11:45 P.M -On 03/11/24 at 12:28 A.M., 3:39 A.M., and 7:45 P.M -On 03/12/24 at 3:45 A.M. and 11:45 A.M Review of the Risk assessment dated [DATE] revealed Resident #139 was at high risk for falls. Review of the At risk for Falls care plan revised 03/13/24 related to poor safety awareness, weakness, low endurance, history of falls, balance issues, diabetic neuropathy and medications. On 03/13/24 at 2:07 P.M., interview with the Director of Nursing verified neurologic checks were not completed per protocol for Resident #139 after the falls on 01/06/24 and 03/10/24 and no fall risk assessment was completed after the fall dated 03/01/24. 2. Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including unspecified dementia, anxiety and history of falls. Review of the admission Fall Risk assessment dated [DATE] revealed resident was at high risk for falls and had three or more falls in past three months. a. Review of the Incident Report dated 03/03/24 revealed during a room check Resident #141 and her roommate were found on the floor. Resident #141 was assisted back to bed, the bed was put in low position and call light placed within reach. The Immediate Action and new intervention was to keep Resident #141's bed in low position when not assisting with care. On 03/13/24 at 8:40 A.M., interview with the Director of Nursing (DON) verified resident beds were to be kept in a low position when not assisting with care and no other intervention had been implemented to prevent further falls. b. Review of the Nurses Notes dated 03/06/24 revealed Resident #141 was found on her hands and knees on the floor. The resident had a small bruise to the palm of her right hand and she stated she did not hit her head. Neuro checks were initiated and no immediate fall intervention was implemented to prevent further falls. Review of the IDT (interdisciplinary team) Note dated 03/07/24 revealed the team reviewed Resident 366001 Page 4 of 8 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #141's fall from 03/06/24 and requested therapy to work with resident on proper exiting from bed using grab bar. On 03/13/24 at 10:23 A.M., interview with Rehab Director (RD) #11 states she was part of the IDT team that reviews falls during daily meeting. RD #11 stated Resident #141 was already receiving therapy for bed mobility at the time of the fall on 03/06/24 and she verbally informed staff to work with her on exiting from the bed using a grab bar but there was no documented evidence this was added to the plan or had been worked on. On 03/13/24 at 11:30 A.M., interview with the DON stated she had not been informed that therapy did not add working with grab bars to Resident #141's treatment plan and verified no other intervention was implemented. c. Review of the Incident Report dated 03/10/24 revealed staff had toileted Resident #141 and put her to bed at 8:15 P.M. and at 8:30 P.M. the resident was heard yelling. Resident #141 was on the floor in her room and was crawling on hands and knees in hallway yelling at another resident to help her up. Neuro checks were initiated and the immediate action was to assist her to the wheelchair and the physician ordered Seroquel (antipsychotic) 25 milligrams to be administered once. On 03/13/24 at 7:45 A.M., interview with the DON stated Seroquel administered once as a fall intervention was not an appropriate fall intervention. 3. Medical record review revealed Resident #69 was admitted on [DATE] with diagnoses including epilepsy, macular degeneration, weakness, dizziness and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact for daily decision-making, and had no falls since the prior assessment. Review of the Nurses Note dated 03/04/24 revealed Resident #69 was lowered to the ground outside. Resident #69 had been outside with her daughter and was walking around the patio space with her walker when she began to lean backwards. Resident's daughter was able to get to resident and stabilize her but was unable to hold her position or assist her back to standing so she lowered her to the ground in a sitting position. The resident stated she stepped back like she usually did and leaned back too far. Therapy to be notified of the resident being lowered to the floor due to a history of vertigo and balance issues. Review of the care plan: At risk for Falls related to medications, seizures, neuropathy, vertigo, and weakness post CVA dated 05/24/22 revealed therapy referral as needed. Review of the record revealed no evidence therapy services screened or evaluated Resident #69 after being lowered to the ground on 03/04/24. On 03/13/24 at 12:44 P.M., interview with the DON stated therapy referral was the intervention for Resident #69's fall on 03/04/24 and was unaware until now that therapy did not screen or evaluate her. The DON stated Rehab Director #11 stated therapy did not screen the resident because she had met her maximum potential in February 2024. The DON verified no other intervention had been implemented to prevent further falls. Review of the policy: Neurologic Assessment (dated 08/15/14) revealed a neurologic assessment was 366001 Page 5 of 8 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to be completed under conditions including an unwitnessed fall, witnessed head injury, resident statement of head injury and/or physician order. The assessment was to be completed and documented in the electronic medical record according to the following schedule and standard of practice: Every 15 minutes x4, every 30 minutes x2, every one hour x4, every four hours x4, and every eight hours x3. Review of the policy: Falls Management (revised 08/18/22) revealed a fall risk assessment will be completed on all residents on admission, readmission, quarterly, with a significant change of condition, and following each fall. A new intervention was to be implemented by the unit staff as soon as possible as well as routine rounding to assess that resident's needs are met. Review of the undated Falls and Falls Risk Clinical Practice Guideline revealed antipsychotic medications including Seroquel can increase fall risk due to syncope, sedation, slowed reflexes, loss of balance and impaired psychomotor function. The goal is to minimize total psychoactive load, use for shortest period of time and taper to avoid adverse withdrawal effects. This deficiency represents non-compliance investigated under Master Complaint Number OH00151792. 366001 Page 6 of 8 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure as needed (PRN) antipsychotic medications were not administered as a fall intervention. This affected one (Resident #141) of three residents reviewed for accidents. The facility census was 77. Findings include: Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including urinary tract infection, unspecified dementia, anxiety and a high fall risk. Review of the admission Physician Orders dated 03/03/24 revealed Resident #141 received Seroquel (antipsychotic) 12.5 milligrams (mg) daily. Review of the Incident Report dated 03/10/24 revealed staff had toileted Resident #141 and put her to bed at 8:15 P.M. and at 8:30 P.M. the resident was heard yelling. Resident #141 was on the floor in her room and was crawling on her hands and knees in the hallway yelling at another resident to help her up. The immediate action was to assist her to the wheelchair and administer a one-time 25mg dose of Seroquel. Review of the Medication Administration Record dated March 2024 revealed Resident #141 received a one-time dose of Seroquel 25 mg on 03/10/24 at 9:35 P.M. for unspecified dementia. On 03/13/24 at 7:45 A.M., interview with the Director of Nursing verified the administration of an antipsychotic medication, such as Seroquel, was not an appropriate fall intervention and this was not standard practice at the facility. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00151792. 366001 Page 7 of 8 366001 03/22/2024 Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect all 77 residents who ate food from the kitchen. Residents Affected - Few Findings include: On 03/12/24 between 10:00 A.M. and 10:23 A.M. , observation of the kitchen revealed the following: 1. The dry storage area had a small window with a window sill that was covered with approximately 30 to 40 small black/brown insects. The insects were dead and two dead bugs were observed on top of a can of condensed milk that was being stored on a shelf underneath the window. 2. The dish room had four black/brown insects with wings that were dead under the storage area and dish table. 3. The opposite end of the dish room contained three carts containing clean coffee pots, 20 clear plastic drinking glasses, various pots and pans and two sets of goggles, three nosey cups and nine water pitchers. A stand up fan was positioned against the back wall and was blowing on the carts with the clean dishes. The fan screen was observed to have dust tendrils adhered to the fan screen and were blowing in the direction of the clean dishes. At the time of the observation, Dietary Manager #21 verified the above findings. Dietary Manager #21 stated the fan was used in the dish room due to poor ventilation and he did not believe it was being used to actually dry the dishes. On 03/13/24 at 10:40 A.M., interview with Dietary Manager #21 stated the facility did not have a policy for kitchen pests, fan use, or cleaning in the kitchen. Dietary Manager #21 stated everything was pulled out in the kitchen, swept and mopped completely at least once a day and as needed. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00151275. 366001 Page 8 of 8