Health inspection·August 9, 2021

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, missing item form review, facility communication form review, resident and staff interviews and review of facility policy, the facility failed to ensure a reported missing item was addressed timely. This affected one (#50) of two residents reviewed for missing items. The facility census was 51. Finding include: Review of the medical record for Resident #50 revealed an admission date of 10/30/17. Diagnoses included intellectual disabilities and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was assessed as having mild cognitive impairment. Resident #50 required supervision with transfers, walking in room and corridor, locomotion on unit and off the unit, and extensive assistance of one person for dressing. Interview and observation on 07/26/21 at 2:40 P.M., with Resident #50 revealed the resident was missing a pair of black shoes and only had a pair of slippers. Resident #50 reported they are supposed to get her new shoes. Resident #50 pointed to a pair of slippers on the floor and reported these were her only pair of shoes. Observed were a pair of slip on slippers. Interview on 07/27/21 at 5:45 P.M., with Social Services #76 revealed missing item logs were maintained. Social Services #76 revealed she handled some of the missing items and shared the list with Housekeeping/Laundry when clothing was involved. At the time of the interview Social Services #76 was not aware of Resident #50's report of a pair of missing black shoes and revealed Resident #50 was on the list for diabetic shoes. Social Services #76 further revealed everything had been recently sent in and now it was just a matter of when they will come out. Social Services #76 provided the missing items logs for 05/2021, 06/2021 and 07/2021 and the evidence of the submission for the diabetic shoes for Resident #50. After reviewing the missing items log for 03/2021, during the interview, Social Services #76 verified the missing item log listed the missing black shoes for Resident #50 dated 03/10/21. Interview on 07/29/21 at 9:30 A.M., with Licensed Nursing Home Administrator (LNHA) revealed he has never seen Resident #50 wear shoes even to appointments. She always wears gripper socks. Missing items logs and forms were used for tracking items, although from around 11/2020 to 03/2021 during the COVID-19 outbreak experienced at the facility, things may have also been done verbally. The entire building was moved around. Page 1 of 12 366028 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/29/21 at 11:02 A.M., with Housekeeping Supervisor #69 revealed missing items logs are maintained by Social Services and then Social Services provides it to the Housekeeping Supervisor. There has only been one given to her since 05/2021 and that was for a different resident. Housekeeping Supervisor #69 was not aware of Resident #50's missing black shoes and reported no black shoes among the missing items in the office. If a resident would like a replacement item, she would go to the LNHA or Social Services to address this. Review of documents titled, Missing Item Form, dated 03/2021, 04/2021, 05/2021, 06/2021 and 07/2021 revealed the report of the missing black shoes for Resident #50 was received on 03/10/21 and there was no indication on the report that the missing item was resolved. Review of document titled, Capital Prosthetic and Orthotic Center Inc. Statement of Certifying Physician for Diabetic and Therapeutic Shoes, dated 05/28/21 revealed the physician had signed the form for the diabetic shoes. Review of document titled, Communication Result Report, dated 06/30/21 revealed a fax was submitted on 06/30/21 from [NAME] Village Care Center to Capital Shoes for the diabetic shoes for Resident #50. Review of facility policy titled, Social Service Grievances/Concerns, dated 01/2021 revealed the facility had a policy in place for missing items. Should a grievance/concern be a missing item, please complete the missing item report, track and trend accordingly. 366028 Page 2 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, observation and policy review, the facility failed to ensure care plans were revised to include an accurate dialysis schedule and smoking interventions. This affected two (#22 and #46) of 20 residents reviewed for care plans. The census was 51. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/01/20 with diagnoses including end stage renal disease, Diabetes Mellitus type two, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #22 was cognitively intact and received dialysis treatments. Review of the active physician order dated 07/08/21 revealed Resident #22 was ordered for dialysis three times per week on Tuesday, Thursday, and Saturday. Review of the Resident #22's comprehensive care plan revealed she is at risk of complications due to dialysis related to end stage renal disease with interventions including resident dialysis days are Tuesday, Thursday, and Saturday. Interview with Licensed Practical Nurse #1 on 07/27/21 at 3:35 P.M., revealed Resident #22 receives dialysis four times per week on Tuesday, Wednesday, Thursday, and Saturday. Interview with Resident #22 on 07/27/21 at 4:37 P.M., revealed she is scheduled to receive dialysis four times per week on Tuesday, Wednesday, Thursday, and Saturday. Interview with Director of Nursing on 07/29/21 at 1:10 P.M., revealed Resident #22 receives dialysis four times per week on Tuesday, Wednesday, Thursday, and Saturday. The interview verified Resident #22's physician order and care plan are inaccurate and do not include her accurate dialysis schedule of four times per week. Review of the facility policy titled Resident Assessment Comprehensive Care Plans, last updated 11/27/17, revealed the comprehensive care plan must describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences. Additionally, the comprehensive care plan must reflect interventions to enable each resident to meet his/her objectives. 2. Review of the medical record for Resident #46 revealed an admission date of 10/01/20. Diagnoses included dementia without behavioral disturbance, pain in right knee, obstructive and reflux uropathy, history of falling, osteoarthritis, seborrheic dermatitis, bunion bilateral feet, history transient ischemic heart attack and insomnia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for mental status score (BIMS) score of 13 indicating intact cognition. Resident #46 required extensive assistance of one person for dressing. Review of the care plan dated 10/01/20 revealed Resident #46 was at risk for injury related to smoking. Resident #46 was assessed as being safe and to be supervised by staff while smoking. Interventions included to utilize smoking apron during smoking activities. 366028 Page 3 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Safe Smoking assessment dated [DATE] revealed Resident #46 was a safe smoker with supervision. Assessment was completed by Director of Nursing (DON). Observation on 07/26/21 at 3:46 P.M. through 3:57 P.M., of the designated smoke break revealed three residents in the smoking [NAME] including Resident #46. Resident #46 was not observed to be wearing a smoking apron. Interview on 07/29/21 at 1:15 P.M., with Activity Director #63 revealed Resident #46 usually once a day in the evenings. Activity Director #63 reported unsampled resident was the only resident who required a smoking apron of all residents who smoke. Interview on 07/29/21 at 2:30 P.M., with DON revealed she completed the most recent smoking assessment for Resident #46. The interview further revealed Resident #46 did not require a smoking apron when smoking. The interview verified Resident #46's care plan was inaccurate when it stated Resident #46 required a smoking apron. 366028 Page 4 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

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, observation, and staff interview, the facility failed to implement fall interventions as care planned. This affected two (#22 and #46) of four residents reviewed for falls. The census was 51. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/01/20, with diagnoses including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set assessment dated [DATE], revealed Resident #22 was cognitively intact and had one fall with major injury since her last assessment. Review of the comprehensive care plan revealed Resident #22 was at risk for falls and subsequent injury with interventions including Don't fall, please call sign at bedside. Observation of Resident #22 and her room on 07/28/21 at 10:48 A.M., revealed there was no Don't fall, please call sign at bedside. Interview with Director of Nursing on 07/28/21 at 10:48 A.M., verified Resident #22 was supposed to have a Don't fall, please call sign at bedside however it was not in place. The Director of Nursing was unaware as to how long the Don't fall, please call sign was not in place. 2. Review of the medical record for Resident #46 revealed an admission date of 10/01/20. Diagnoses included dementia without behavioral disturbance, pain in right knee, obstructive and reflux uropathy, history of COVID-19, retention urine, history of falling, osteoarthritis, seborrheic dermatitis, bunion bilateral feet, history transient ischemic heart attack and insomnia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognition. Resident #46 required extensive assistance of one person for dressing and toilet use, limited assist of one person for transfers, walking in room. Resident #46 was independent with set up for personal hygiene and required one-person physical help in part of bathing. Resident #46 was not steady when moving from a seated to standing position and surface to surface transfers. Review of the most recent fall risk assessments dated 03/24/21 and 04/07/21 revealed Resident #46 was a high risk for falls. Review of the current care plan dated 10/01/20 revealed Resident #46 was at risk for falls and subsequent injury related to history of falls prior to admission, use of mobility device, impaired cognition, arthritis in knees and an indwelling Foley catheter. Fall interventions included to purchase and mount a support device to the countertop in the bathroom with a date initiated 03/02/2021. Review of fall summary dated 03/02/21 revealed Resident #46 had a fall. On 03/02/21, Resident #46 was reported to have been walking in the bathroom, washed his hands, turned around to reach for walker, lost his balance and fell. Resident #46 was found sitting on his buttocks inside of the bathroom. New intervention included to purchase and mount a support device and adhere it to the countertop in the bathroom. Observation on 07/28/21 at 4:40 P.M., revealed no assistive devices mounted on the countertop in 366028 Page 5 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0689 the bathroom. Level of Harm - Minimal harm or potential for actual harm Interview on 07/28/21 at 4:40 P.M., with Resident #46 revealed he has never had an assistive device mounted on the countertop. Residents Affected - Few Interview and concurrent observation on 07/28/21 at 5:05 P.M., with Director of Nursing (DON) revealed there were no assistive devices mounted on the countertop. DON confirmed a pair of circular handled assistive devices were sitting unattached on the top of the counter and maintenance was going to apply them. When asked when this was discovered, DON reported they just found out now they were not in place. DON verified the current care plan indicated fall interventions included to purchase and mount a support device to the countertop in the bathroom with a date initiated 03/02/2021. Review of facility policy titled, Care Standards Fall Prevention and Management Policy, revised 02/2020 revealed the purpose of the policy was to assess resident risk for falls and implement interventions to reduce the incidence of falls and/or mitigate the risk of injury related to falls. This deficiency substantiates Complaint Number OH00124553. 366028 Page 6 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility failed to ensure the care and treatment of indwelling catheters was provided to prevent possible infections and maintained to prevent urine from leaking and exposing others to possible infections. This affected three residents (#45, #47 and #14) of five residents who had indwelling catheters. The facility census was 51. Findings include: 1. Review of Resident #45's medical record revealed an admission date of 03/23/07. Diagnoses included multiple sclerosis, presence of urogenital implants, neuromuscular dysfunction of the bladder, and retention of urine. Review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] listed the resident has having an indwelling catheter. Review of Resident #45's monthly physician orders dated July 2021 revealed the resident had an order to flush suprapubic catheter twice a day. Observation on 07/28/21 at 2:11 P.M., of Resident #45's bathroom revealed two plastic measuring devices sitting on the back of the resident's toilet. One was a urinary collection container and the other container sitting next to the urine container was labeled suprapubic flush. Both collection containers were uncovered without a barrier. Interview on 07/28/21 at 2:20 P.M., with Licensed Practical Nurse (LPN) #10 verified the two collection containers were on the back Resident #45's toilet and were improperly stored. 2. Review of Resident #47's medical record revealed an admission date of 03/18/20. Diagnoses included epilepsy, pneumonitis, pressure ulcer, heart failure, bipolar, diabetes, depressive disorder, chronic respiratory failure, and dysphagia. Review of Resident #47's MDS assessment dated [DATE] listed the resident as having an indwelling catheter. Review of Resident #47's monthly physician orders dated July 2021 revealed for catheter care every shift and change ostomy bag every five days and as needed. Observation on 07/26/21 at 11:29 A.M., of Resident #47's bathroom revealed a urine collection container sitting next to a collection container labeled colostomy on the back of the resident's toilet. Both collection containers were uncovered with no barriers. Observation on 07/28/21 at 2:00 P.M., of Resident #47's bathroom revealed a urine collection container sitting on the back of the toilet next to a collection container labeled colostomy. The container labeled colostomy had a small amount of feces in the container. Both collection containers were uncovered with no barriers. Interview on 07/28/21 at 2:08 P.M., with LPN #10 verified the urine and colostomy collection 366028 Page 7 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0690 containers were improperly stored. LPN #10 then took both containers and threw them into the trash. Level of Harm - Minimal harm or potential for actual harm 3. Observations on 07/26/21 at 11:49 A.M., revealed Resident #14 in the dining room, his catheter bag was leaking. State Tested Nurse Assistant (STNA) #38 was alerted and STNA #38 asked Resident #14 to come with her down the hall to a shower room, while the catheter bag continued to leak down the hall. Because the shower room was occupied, Resident #14 was lead further down the hall to his room, with the catheter bag leaking. A trail of urine was observed on the floor from the dining room, common area, nurses station, past the rehab unit entry and to Resident #14's room. The staff made no attempt to contain the leaking urine. Residents Affected - Few Observation on 07/26/21 at 11:53 A.M., revealed LPN #10 notified housekeeping to clean the contaminated areas. While waiting for housekeeping to arrive there were two residents in the common area, five staff walked through the areas carrying meal trays to be delivered. At 11:56 A.M., the housekeeping was observed to arrive and begin the clean up. Interview on 07/26/21 at 11:55 A.M., with the Administrator verified Resident #14's catheter bag was leaking and not contained as the resident was transported from the dining room. 366028 Page 8 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, observation, staff interview, and facility policy, the facility failed to ensure oxygen was set at physician ordered liter flow. This affected two residents (#19 and #26) of nine residents who receive oxygen. The facility census was 51. Residents Affected - Few Findings include: 1. Review of Resident #19's medical record revealed an admission date of 07/21/20. Diagnoses included malignant neoplasm of right bronchus, COVID-19, acute and chronic respiratory failure with hypoxia, diabetes, obstructive sleep apnea, and anxiety disorder. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] listed the resident as receiving oxygen. Review of Resident #19's physician order dated 07/21/20 revealed an order for oxygen per nasal cannula at three liters per minute continuously for resident comfort or oxygen saturations below 88%. Observation on 07/28/21 9:30 A.M., of Resident #19 revealed the resident's oxygen concentrator was set at 4.5 liters per minute via nasal cannula. Interview on 07/28/21 10:54 A.M., with Licensed Practical Nurse (LPN) #10 verified Resident #19's oxygen should be set at three liters per minute and not 4.5 liters per minute. 2. Review of Resident #26's medical record revealed an admission date of 05/14/21. Diagnoses included encephalopathy, anoxic brain damage, chronic respiratory failure with hypoxia, personal history of transient ischemic attack and cerebral infarction without deficits, contractures left hand, and tracheostomy status. Review of Resident #26's MDS assessment dated [DATE] listed the resident as receiving oxygen and having a tracheostomy. Review of Resident #26's physician order dated 05/14/21 revealed an order for oxygen four liters via mask 31%. Observation on 07/28/21 at 9:10 A.M., of Resident #26 revealed a tracheostomy mask in place and oxygen concentrator set at one liter per minute. Interview on 07/28/21 at 10:33 A.M., with LPN #17 verified Resident #26's oxygen concentrator was set at one liter per minute and the physician's order is for four liters per minute. Review of facility policy titled Oxygen Therapy dated July 2021, revealed oxygen will be administered per physician order and by qualified personnel. 366028 Page 9 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to address pharmacist medication regimen review recommendations. This affected one (#22) of six residents reviewed for unnecessary medications. The census was 51. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/01/20, with diagnoses including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of the Resident #22's pharmacist drug regimen review dated 06/11/21 revealed the pharmacist documented for the facility to please take the following action and see the report. Interview with Director of Nursing on 07/29/21 at 2:30 P.M. revealed she did not know if Resident #22 had any pharmacist recommendations for June 2021 and the facility did not have a copy of any pharmacist recommendations for June 2021. No pharmacist recommendations for Resident #22 from June 2021 were provided to the state surveyors prior to the end of the annual survey. Review of the policy titled Psychotropic Medication Use Policy dated 07/2021, revealed if antipsychotropics are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement care-planned, non pharmalogical approaches, and ongoing evaluation of the effectiveness of these interventions. 366028 Page 10 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of facility policies, the facility failed to ensure there was a functioning thermometer in the unit refrigerators and freezers and staff were monitoring the temperature of the unit refrigerators and freezers. This affected 48 of 48 residents who potentially receive food/drinks from the unit refrigerators. The facility identified three (#21, #26, and #34) residents that receive nothing by mouth. The census was 51. Findings include: Observation on 07/28/21 at 2:07 P.M., revealed the refrigerator at the north nurse's station had a thermometer with a reading of 41 degrees Fahrenheit and no logs were posted for monitoring temperatures. Observation on 07/28/21 at 2:11 P.M., revealed the refrigerator and freezer at the south nurse's station did not contain a thermometer and no logs were posted for monitoring temperatures. Interview on 07/28/21 at 2:11 P.M., with Licensed Practical Nurse (LPN) #10 verified the refrigerator at the south nurse's station did not contain thermometers in both the refrigerator and the freezer. LPN #10 was not sure where they kept the temperature logs and reported she will check on them. Interview and concurrent observations on 07/28/21 at 3:50 P.M., with Dietary Manager #70 revealed housekeeping and nursing maintain the temperature logs for the unit refrigerators. Dietary Manager #70 verified the south unit freezer did not contain a thermometer and there was now a thermometer mounted in the south unit refrigerator. Dietary Manager #70 verified the north unit refrigerator had a thermometer that was reading 42 degrees Fahrenheit and reported this was not a good thermometer and needed to be replaced. Dietary Manager #70 verified there were no posted temperature logs on the north and south unit refrigerators and freezers. Dietary Manager #70 reported he would check to see where they were being maintained. A look back period of three months was requested. Interview on 07/28/21 at 4:16 P.M., with Dietary Manager #70 revealed staff were not keeping a temperature log for the north unit refrigerator and south unit refrigerators. The interview verified the previous thermometer located in the north unit refrigerator was old and inaccurate, and there was no thermometer located in the south unit refrigerator and freezer. Observation on 07/29/21 at 8:40 A.M., revealed the 07/2021 temperature logs were now posted on refrigerator and freezer on both units. During the course of the survey, no temperature logs for the unit refrigerators and freezers were provided for the three month look back requested. Reviewed facility policy titled, Dietary Manual Food Temperature Records/Controls revision date 04/2021, revealed the facility had a policy in place related to food storage temperature monitoring and thermometers. Procedures included thermometers shall be in all refrigerators, freezers, and storage areas. There should be immediate follow-up on refrigerator and freezer temperature deviations to correct the problem. Reviewed facility policy titled, Dietary Manual Foods Brought In To Resident Education Material, 366028 Page 11 of 12 366028 08/09/2021 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0812 Level of Harm - Minimal harm or potential for actual harm revision date 04/2021, revealed the facility had a policy in place related to cold holding of foods indicating *Note: Thermometers will be periodically checked to ensure proper calibration. Basic food handling precautions: Hot Foods at or > 165 degrees, Cold Foods at or < 41 degrees. Policy further indicated ensuring safe food handling once the food is brought to the facility including safe reheating and hot/cold holding and handling of leftovers. Residents Affected - Many 366028 Page 12 of 12