Health inspection·November 16, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on record review, resident interview, and staff interview, the facility failed to ensure residents were invited to attend their care conference, and encouraged to participate in the development, implementation, and revision of the person-centered care plan. This affected one (Resident #51) of 17 residents reviewed for care plans. The facility census was 69. Findings include: Review of the medical record for Resident #51 revealed an admission date of 12/17/21. Diagnoses included type II diabetes mellitus, cerebral infarction, and acute on chronic congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/13/23, revealed Resident #51 was cognitively intact. Resident #51 was not coded as having any behaviors or rejection of care. Review of Resident #51's care plan revealed the care plan did not mention Resident #51 refused or rejected care. Review of the care conference progress notes revealed Resident #51 had two care conferences in the past 12 months on 11/08/22 and 02/08/23. On 11/08/22, the only recorded participants were Resident #51 and Licensed Social Worker (LSW) #768. There was no evidence that Resident #51's charge nurse, a state tested nursing aide (STNA), or a dietary representative attended. On 02/08/23, the only recorded participants included LSW #768 and the Director of Nursing (DON). There was no evidence Resident #51 was invited to attend his care conference on 02/08/23. An interview on 11/16/23 at 1:33 P.M. with Resident #51 revealed he was unable to recall being invited or having a care conference regarding his ongoing care at the facility. An interview on 11/16/23 at 1:53 P.M. with LSW #768 verified Resident #51 had only two care conferences in the 12 months and Resident #51 was not invited to attend the care conference held on 02/08/23. LSW #768 also verified the care conferences held on 11/08/22 and 02/08/23 did not include an interdisciplinary team. Page 1 of 14 366028 366028 11/16/2023 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 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 resident and staff interviews, record reviews, and review of the facility policy, the facility failed to timely investigate reported missing personal items and follow up with the residents with results of the investigation. This affected one (Resident #14) of one resident reviewed for missing items. The facility census was 69. Findings include: Record review for Resident #14 revealed an admission date of 04/03/21. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage one through stage four chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of the Missing Item Report dated 10/20/23 revealed Resident #14 had reported pajamas that were black with white magnolia flowers that were missing along with a blanket that was grey brown on one side and the other side was white with colored rectangles and a tag that said 'BB'. The Missing Item Report dated 10/27/23 revealed Resident #14 had reported a baby [NAME] shirt missing. Interview on 11/14/23 at 11:43 A.M. with Resident #14 revealed her granddaughter bought her pajamas that were black with white magnolia flowers for Christmas last year. Resident #14 stated the pajamas had her name on them, they were special to her because her granddaughter got them as a gift and they were beautiful. Resident #14 stated the pajamas were missing for a few months. She told Licensed Social Worker (LSW) #768 and laundry staff over and over and nothing happened. Resident #14 stated she also had a green blanket with baby [NAME] missing for over a month and a baby [NAME] shirt she reported missing about a week ago. Interview on 11/14/23 at 2:35 P.M. with LSW #768 confirmed Resident #14's missing items were documented in the facility's Missing Items Report. If a resident was missing an item, they would either come to her or housekeeping. A missing item form would be filled out then it would be discussed in the following morning meeting so every department head would know. Housekeeping staff would look in the lost and found and laundry area and report back to her (LSW #768) if the item was found or not. LSW #768 revealed the facility would look for two to three weeks. The facility never replaced any resident missing items reported by residents since she had been there and she had been there in her position for over a year. LSW #768 revealed if the missing item was not found, the facility would not follow up with the resident. The resident would only be made aware if the item was found. LSW #768 confirmed she was responsible for tracking and following up with missing items reported and confirmed she did not follow up with residents if the reported missing item was not found. The housekeeping supervisor was still looking for Resident #14's missing items and confirmed she never followed up with Resident #14 regarding her missing items. LSW #768 stated she would bring it back up to the Administrator to talk about replacing the missing items. Interview on 11/14/23 at 4:04 P.M. with the Administrator revealed there was a form for missing items located outside the laundry door. The form needed to be filled out when a resident reported a missing item. The form started with the laundry supervisor then would be given to the LSW to track. Sometimes missing items were discussed in the morning meeting. Once the missing item was reported, the staff would look for the item. The Administrator stated the response should be back to the resident, 366028 Page 2 of 14 366028 11/16/2023 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 if the item was found or not, in two to three days. The Administrator stated it would not be acceptable to not get back to the resident with a response if the item was found or not. The Administrator stated generally he would also go to the resident and talk to them. If the item was not found, the facility would replace the item in a day or two from the time he talked to them. The Administrator stated it had been over a year ago since the facility replaced a missing item. The Administrator stated no one told him Resident #14 was missing items. Subsequent interview on 11/14/23 at 4:54 P.M. with the Administrator stated Resident #14's missing shirt was found in her dresser drawer. The Administrator confirmed the staff should have looked sooner and stated he did not find the blanket or pajamas. The Administrator stated he checked with Resident #14's family and they did not have the missing items. Interviews on 11/16/23 between 1:09 P.M. and 1:22 P.M. with State Tested Nursing Assistant (STNA) #731, #735, and #702 stated they have seen Resident #14 wearing here pajamas and blanket in the past before they were reported missing. Interview on 11/16/23 at 1:24 P.M. with Laundry Supervisor (LS) #742 confirmed the facility washed Resident #14's laundry. LS #742 was unable to locate Resident #14's missing items. LS #742 was first notified of Resident #14's missing blanket and pajamas in the middle of October (when she first took over the Laundry Supervisor position) by Resident #14. After Resident #14 discussed it with LS #742, she spoke to the previous Laundry Supervisor who told her to keep looking and she (previous Laundry Supervisor) was also aware and revealed they had been missing a few months. Laundry Supervisor #742 filled out the missing item report and gave LSW #768 a copy of the missing item report in October. However, the previous laundry supervisor did not provide a copy of the missing item report to the LSW back when it was reported to her (previous laundry supervisor). Review of the policy titled Social Services, Grievances/Concerns. reviewed 01/2022, revealed to support each resident's rights to voice grievances and to ensure a policy is in place to process grievances. Providing prompt action to resolve grievances/concerns and to keep the resident appraised of the progress towards resolution. The Administrator is the Grievance Officer who is responsible and will oversee the implementation of the facility grievance process, receiving and tracking grievances through to their conclusion with the Social Service Director. The policy included all grievances received will be investigated within 72 hours following receipt of the complaint. Within seven days following the receipt of the complaint, the facility will inform the complainant with the result of the investigation in writing. Should the grievance or concern be a missing item, please complete the missing item report, track and trend accordingly. 366028 Page 3 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility policy, the facility failed to timely provide a resident with the bed hold policy acknowledgement to include the number of bed hold days. This affected one (Resident #64) of one resident reviewed for receipt of bed hold days upon facility transfer of a resident. The facility census was 69. Findings include: Record review for Resident #64 revealed an admission date of 08/27/22. Diagnoses included malignant neoplasm of bladder and acute respiratory failure with hypoxia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Review of the face sheet for Resident #64 revealed Resident #64 had no information available for contacts. Review of the facility census for Resident #64 revealed on 05/07/23, Resident #64 had a hospital leave and returned to the facility on [DATE]. On 05/14/23, Resident #64 had a hospital leave and returned to the facility on [DATE]. On 08/13/23, Resident #64 had a hospital leave and returned to the facility on [DATE]. On 09/06/23, Resident #64 had a hospital leave and Resident #64 did not return to the facility. Review of the Bed Hold Policy Acknowledgement for Resident #64 dated 05/07/23 (as date notice issued) signed by Licensed Social Worker (LSW) #768 revealed the number of therapeutic bed hold days were not filled in. The form was signed by Resident #64 and dated 05/07/23 next to his name in a different colored pen. Review of the Bed Hold Policy Acknowledgement for Resident #64 dated 05/14/23 (as date notice issued) signed by LSW #768 revealed the number of therapeutic bed hold days were not filled in. The form was signed by Resident #64 and dated 05/14/23 next to his name in a different colored pen. Review of the Bed Hold Policy Acknowledgement for Resident #64 dated 08/13/23 (as date notice issued) signed by LSW #768 and it was not signed by Resident #64. The form was pre-dated 08/13/23 next to where the resident would sign. The number of therapeutic bed hold days were not filled in. Review of the Bed Hold Policy Acknowledgement for Resident #64 undated, signed by LSW #768 revealed the number of therapeutic bed hold days were not filled in and was not signed by resident. Interview with LSW #768 between 11/15/23 at 4:50 P.M. and 11/16/23 at 2:02 P.M. confirmed she was to provide residents including Resident #64 with bed hold days notification when they were transferred to the hospital or had a leave of absence. Resident #64 did not have a contact person to notify so she would give the notice to Resident #64 when he returned from the hospital. LSW #768 confirmed she never attempted to provide the Bed Hold Policy Acknowledgement to Resident #64 prior to him returning to the facility. LSW #768 confirmed the date next to Resident #64's signature (that was to be the date he received the bed hold days) was not the date he received it, this was the date pre-filled in by her which was backdated to the date of his transfer to the hospital. LSW #768 stated that was what she was told to do when she started working at the facility. LSW #768 confirmed she did not complete the forms dated 05/07/23, 05/14/23, 08/13/23, or 09/06/23 to include the bed hold days. LSW #768 confirmed Resident #64 did not receive any transfers or bed hold acknowledgement for 08/13/23 or 366028 Page 4 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0625 09/06/23. Level of Harm - Minimal harm or potential for actual harm Interview on 11/16/23 at 2:10 P.M. with the Administrator revealed the resident should be made aware of the amount of bed hold days they have left in the documentation of the Bed Hold Policy Acknowledgement. The date signed should be the date the resident signed they received the form and should not be pre-filled in to the date they left the facility. Residents Affected - Few Review of the policy titled Social Service/Bed Hold, reviewed 01/2022, revealed the facility shall provide the bed hold policy Acknowledgement to the resident or the resident's representative with any resident initiated therapeutic leave or transfer to alternative healthcare community including a hospital admission. This acknowledgement will provide information to the resident and or representative that explains the duration, the reserved bed payment policy and also facility permitting return of the resident to the next available bed. In the event of an emergency transfer to the hospital, the facility social worker or designee will attempt to contact the resident or the residents representative within 24 hours of the transfer and determine rather to hold the resident bed. The facility will document multiple attempts if necessary to reach the resident and or the residents representative in cases where the facility was unable to notify. 366028 Page 5 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0641 Ensure each resident receives an accurate assessment. 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 accurately code the resident's Minimum Data Set (MDS) 3.0 assessments. This affected three (#10, #50, and #51) of 17 residents reviewed during the investigative process. The facility census was 69. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 10/19/23. Diagnoses included metabolic encephalopathy, expressive language disorder, and intellectual disabilities. Review of the admission MDS 3.0 assessment, dated 10/23/23, revealed Resident #10 was coded to have bipolar disorder. Review of the medical record revealed no evidence that Resident #10 had been diagnosed at any time with bipolar disorder. An interview on 11/16/23 at 11:20 A.M. with MDS Coordinator #715 verified Resident #10 did not have bipolar disorder and it was coded on the MDS assessment dated [DATE] in error. 2. Review of the medical record for Resident #50 revealed an admission date of 10/18/21. Diagnoses included chronic kidney disease, dependence on renal dialysis, cerebral infarction, and depression with atypical features. Review of the discontinued physician's orders revealed Resident #50 received Zyprexa (an antipsychotic medication) 5.0 milligrams (mg) daily at bedtime from 07/10/22 to 04/21/23. Resident #50 received Zyprexa 2.5 mg daily at bedtime from 04/22/23 to 08/08/23. Review of current physician's order, dated 08/09/23, revealed Resident #50 had an order for Zyprexa 2.5 mg every other day at bedtime. Review of the consultant pharmacist medication regimen report revealed gradual dose reductions were requested by the consultant pharmacist and approved by Resident #50's physician on 04/21/23 and 08/09/23. Resident #50's medical record contained no evidence that the physician documented gradual dose reductions as contraindicated. Review of the quarterly MDS 3.0 assessment, dated 10/16/23, revealed Resident #50 was marked as not receiving a gradual dose reduction of the antipsychotic medication. Additionally, the assessment identified the physician documented a gradual dose reduction of the antipsychotic medication as clinically contraindicated on 08/09/23. An interview on 11/16/23 at 8:55 A.M. with MDS Coordinator #715 verified the gradual dose reduction information was entered into the MDS assessment incorrectly for Resident #50 on 10/16/23. MDS Coordinator #715 further verified she struggled to find this information as she does not receive copy of the pharmacist's recommendations and many times this information was not readily available in the resident's medical record. 3. Review of the medical record for Resident #51 revealed an admission date of 12/17/21. Diagnoses included type II diabetes mellitus, cerebral infarction, and acute on chronic congestive heart failure. 366028 Page 6 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #51 refused care or services on 10/07/23, 10/08/23 and 10/10/23. Resident #51's MAR additionally indicated that he received metformin (an oral hypoglycemic medication) 750 milligrams (mg) once daily in the morning every day during the month of October 2023. Review of the quarterly MDS 3.0 assessment, dated 10/13/23, revealed Resident #51 was coded to have no behaviors and was not coded to have received hypoglycemic medication during the seven-day look back period. An interview on 11/16/23 at 8:55 A.M. with MDS Coordinator #715 verified Resident #51 should have been coded as having received hypoglycemic medication on the MDS assessment dated [DATE]. MDS Coordinator #715 stated Licensed Social Worker (LSW) #768 was primarily responsible for coding the information about behaviors. MDS Coordinator #715 verified based on behavior monitoring on the MAR, behavior of rejection of care should have been marked as occurring on one to three days during the seven-day look back period. 366028 Page 7 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #117's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular disorder of the intestine, surgical after care following surgery on the digestive system, and type two diabetes mellitus. Review of the admission-critical admission assessment dated [DATE] revealed Resident #117 had an abdominal incision, and was alert, talkative and able to make her needs known. Review of the medical record revealed Resident #117 did not have a care conference at the facility and there was no documentation of the resident participating in the care plan process or receiving a copy of her baseline care plan. Interview with Resident #117 on 11/13/23 at 2:28 P.M. revealed she had not participated in a care conference, had not been asked to assist in the completion of the care planning process, or provided a copy of her care plans. Interview with Licensed Social Worker (LSW) #768 on 11/14/23 at 3:18 P.M. verified Resident #117 had not been included or participated in the care conference process which included formulation and implementation of the care plans at the facility. Interview with Registered Nurse #714 on 11/16/23 at 10:52 A.M. revealed she was the staff member who puts in the resident's baseline care plans on admission. RN #714 confirmed if a resident is admitted over the weekend, she would put the baseline care plan in on Monday. RN #714 stated her responsibility included entering the baseline care plans in the electronic health record. 4. Review of Resident #121's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, hemiparesis following a cerebrovascular accident, malignant neoplasm of the ovary, and urinary tract infection. Review of the medical record on 11/14/23 revealed Resident #121 did not have a care conference at the facility and there was no documentation of the resident participating in the care plan process or receiving a copy of her baseline care plans. Interview with Licensed Social Worker (LSW) #768 on 11/14/23 at 3:18 P.M. verified Resident #121 had not been included or participated in the care conference process which included formulation and implementation of the care plans at the facility. Interview on 11/15/23 at 2:38 P.M. with Resident #121 and her husband revealed the facility had not provided them with a copy of the resident's care plan and the facility had completed one care conference with them on 11/14/23. The resident and family denied having been included in the care planning process and having a baseline care conference within 48 hours of admission. Review of the facility policy titled Resident Baseline Care Plan Development, updated 01/17/18, revealed the intent was to ensure each resident received necessary care and services upon admission. Completion and implementation of the baseline care plan within 48 hours of the residents admission is intended to promote continuity of care and communication among nursing staff, increase resident 366028 Page 8 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some safety and safeguard against adverse advents that are most likely to occur right after admission; and to ensure the resident and representative are informed of the initial care plan for delivery of care and services by receiving a written summary of the baseline care plan. 2. Record review for Resident #49 revealed an admission date of 09/19/23. Diagnoses included hydronephrosis with urethral stricture, chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, abdominal aortic aneurysm, benign prostatic hyperplasia, cirrhosis of liver, neuromuscular dysfunction of bladder, and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. Review of the baseline care plan dated 09/19/23 revealed Resident #49 was a new admission to the facility and in need of nursing care service. There was no evidence the family and/or resident received a copy of the baseline care plan. Interview on 11/13/23 at 1:28 P.M. with Resident #49's primary contact person (family) confirmed they had not been included in any care conferences at the facility and denied having any care plans provided to them. Interview on 11/15/23 at 3:50 P.M. with Licensed Social Worker (LSW) #768 confirmed Resident #49 (including his family) never had a care conference at the facility. Interview on 11/15/23 at 4:02 P.M. with Unit Manager (UM) #714 confirmed she completed all residents initial care plans upon admission and within 48 hours reviewed the initial care plans with the family or resident. UM #714 revealed she does not document when she reviews the care plan or when she gives the family a copy of the care plans. UM #714 stated she did not recall if she reviewed Resident #49's care plan with his Resident #49's primary contact person (family) and confirmed she does not track who she does them with or when. UM #714 confirmed she was the only staff member who did the initial care plans and the only one who reviewed them with the residents and or families upon admission. Based on medical record review, family, resident, and staff interviews, and review of the facility policy, the facility failed to provide a copy of the baseline care plan to the resident and their representative. This affected four (Residents #49, #117, #121, and #219) of 17 residents reviewed for care plans. The facility census was 69. Findings include: 1. Record review for Resident #219 revealed an admission date of 11/11/23. Diagnoses included cutaneous abscess of left lower limb, diabetes mellitus, cerebral infarction, and congestive heart failure. Review of the baseline care plan, initiated on 11/11/23, revealed Resident #219 was a new admission to the facility and was in need of nursing care services. Resident #219 required assistance with activities of daily living. There was no evidence the baseline care plan included Resident #219 and there was no evidence Resident #219 received a copy of the baseline care plan An interview on 11/15/23 at 4:03 P.M. with Unit Manager (UM) #714 revealed she was responsible for the initial/baseline care plans for new residents at the facility. The facility enters the baseline care plan under the care plan section in the electronic health record. UM #714 stated she prints the 366028 Page 9 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care plan, gives a copy to the resident and/or family, but does not document that meeting anywhere. UM #714 stated the goal was to have the baseline plan of care completed within 48 hours of a new resident's admission to the facility. An interview on 11/15/23 at 4:25 P.M. with Resident #219 revealed an unnamed nursing staff member came to discuss his plan of care with him earlier in the day on 11/15/23 for the first time since he admitted on [DATE]. Resident #219 further stated that staff member stated they would be back with a copy of his plan of care, but no one ever came back. A follow up interview on 11/16/23 at 8:15 A.M. with Resident #219 revealed he still had not received a copy of his baseline plan of care, nor had be been involved in the initial care planning process. An interview on 11/16/23 at 10:49 A.M. with UM #714 verified she did not believe Resident #219 received a copy of his baseline care plan. 366028 Page 10 of 14 366028 11/16/2023 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** 3. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, obstructive sleep apnea, atrial fibrillation, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was cognitively intact, had no behaviors, was at risk for pressure ulcer, and received anticoagulant and diuretic medication. Resident #58 had MDS assessments completed on the following dates: on 05/08/23 (admission), on 07/16/23 (quarterly), and on 10/05/23 (quarterly). Review of the medical record revealed Resident #58 had one care conference on 06/28/23. No other care conferences were documented for Resident #58. Interview with Licensed Social Worker (LSW) #768 on 11/14/23 at 3:18 P.M. verified Resident #58 had not been included or participated in the routine care conference process that correlated with the comprehensive MDS assessment, and the facility had completed only one care conference on 06/28/23 for Resident #58. Review of the policy titled Comprehensive Resident Care Plan, reviewed on 01/2022, revealed the comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Reviews with necessary revisions will be conducted quarterly per the Resident Assessment Instrument (RAI) (MDS) defined schedule. The resident and his/her family, resident representative and/or the legal representative are invited to attend and participate in the resident's assessment and care planning conference. The Social Services Director or designee is responsible for contacting the resident's family and for maintaining records of such notices. The facility's procedure included the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans, which included at least quarterly. A seven day advance notice of the care planning conference is provided to the resident and interested family members. Such notice is made by mail and/or telephone. The Social Services Director or designee is responsible for contacting the resident's family and for maintaining records of such notices. Notices include the date, time and location of the conference; the name of each family member and the date he or she was contacted; the method of contacting the family (e.g., mail, telephone, email, etc.); input from family members and/or resident when they are not able to attend; refusal of participation, if applicable; and the date and signature of the individual making the contact. Based on record review, resident and staff interview, and facility policy review, the facility failed to the resident's care plans were developed and reviewed with an interdisciplinary approach and failed to ensure the care plans were reviewed following the completion of the Minimum Data Set 3.0 assessments. This affected three (#14, #51, and #58) of eleven residents reviewed during the investigative process who were not recently admitted to the facility. The facility census was 69. Findings include: 366028 Page 11 of 14 366028 11/16/2023 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 1. Record review for Resident #14 revealed an admission date of 04/03/21. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage one through stage four chronic kidney disease. Type two diabetes mellitus, iron deficiency anemia, intestinal malabsorption, and morbid obesity due to excessive calories. Review of the care plans dated 04/03/21 revealed the disciplines involved were dietary, nursing and the physician. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Resident #14 was independent with eating, required substantial assistance from staff with bed mobility and was dependent on staff for transfers. Resident #14 had a weight gain of five percent or more over the last month. Resident #14 had previous MDS assessments completed on the following dates: 01/12/22 (quarterly), 03/31/22 (quarterly), 07/01/22 (quarterly), 10/01/22 (annual), 01/09/23 (quarterly), 04/11/23 (quarterly), 07/12/23 (quarterly), 08/21/23 (quarterly), and 11/16/23 (annual). Review of the care conference progress notes for 2022 and 2023 revealed a care conference for Resident #14 was held on 04/14/22, 12/14/22, 03/29/23, and 06/06/23. The care conference progress notes held on 04/14/22, 12/14/22, 03/29/23, and 06/06/23 revealed the attendees did not include Resident #14's charge nurse, state tested nursing assistant (STNA) or a representative from dietary. Interview on 11/13/23 at 10:51 A.M. with Resident #14 revealed she and her daughter had a care plan meeting with the the Director of Nursing (DON) and Licensed Social Worker (LSW) #768 a long while ago but none recently. Interview on 11/14/23 between 3:04 P.M. and 4:56 P.M. with LSW #768 revealed the interdisciplinary team members were told of the scheduled care conferences in morning meeting. LSW #768 revealed the DON attended the care conferences and if the resident was on therapy, then they were also asked to attend. LSW #768 confirmed no dietary personnel attended care conferences, no floor STNAs or charge nurses were asked to attend and no physicians or Nurse Practitioners were asked asked to attend any of the resident care conferences. LSW #768 confirmed Resident #14 did not have a care conference within seven days of the resident assessments being completed and the facility did not complete the quarterly care conferences for Resident #14 which should have been completed in January 2022, July 2022, October 2022, January 2023, April 2023, and July 2023. Interview on 11/14/23 at 4:57 P.M. with Dietary Manager #708 revealed he was employed as the Dietary Manager at the facility for over a year. Dietary Manager #708 confirmed he did not attend any resident care plan meetings including for Resident #14. Dietary Manager #708 revealed the facility utilized a consulting dietitian and that person also did not attend any resident care plan meetings. 2. Review of the medical record for Resident #51 revealed an admission date of 12/17/21. Diagnoses included type II diabetes mellitus, cerebral infarction, and acute on chronic congestive heart failure. Review of Resident #51's care plan revealed the resident was at risk for falls, to be occasionally incontinent of bowel and bladder, and at risk for skin breakdown. Resident #51 was identified to be a supervised smoker. Resident #51 was noted to have poor activity participation due to choosing not to attend structured activities. The care plan did not mention Resident #51 refused or rejected care. 366028 Page 12 of 14 366028 11/16/2023 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 quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/13/23, revealed Resident #51 was cognitively intact. He was not coded as having any behaviors or rejection of care. Resident #51 had previous MDS assessments completed on the following dates: 12/19/22 (annual), 01/18/23 (quarterly), 04/12/23 (quarterly), 07/13/23 (quarterly), and 10/13/23 (quarterly). Review of the care conference progress notes in the last 12 months revealed care conferences were held for Resident #51 on 02/08/23 and 11/08/22. On 02/08/23, the only recorded participants included Licensed Social Worker (LSW_ #768 and the Director of Nursing (DON). On 11/08/22 the only recorded participants were Resident #51 and LSW #768. There was no evidence that Resident #51's charge nurse, a STNA, or a dietary representative attended. An interview on 11/16/23 at 1:33 P.M. with Resident #51 revealed he was unable to recall being invited or having a care conference regarding his ongoing care at the facility. An interview on 11/16/23 at 1:53 P.M. with LSW #768 verified Resident #51 had only one care conference in the past year and the schedule for care conference did not follow the MDS schedule. LSW #768 verified the care conferences were not completed with an interdisciplinary team (IDT) approach and were not reviewed quarterly with the IDT. 366028 Page 13 of 14 366028 11/16/2023 Woodside Village Care Center 841 W Marion Rd Mount Gilead, OH 43338

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, policy review, and review of the manufacturer instructions, the facility failed to administer medications to the residents without a significant medication error. This affected one (Resident #5) of one resident observed for insulin administration. The facility census was 69. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Review of the physician's orders revealed Resident #5 had an order for Basalar Kwik pen U-100 insulin 100 units per milliliter (ml) administer 30 units subcutaneously twice daily. Observation of Resident #5 receiving medication on 11/15/23 at 7:16 A.M. provided by Registered Nurse (RN) # 713 revealed RN #713 prepared the Basalar Kwik pen by cleaning the stopper of the pen with an alcohol wipe, placing a disposable needle on the end of the pen, and dialed the pen to the physician ordered dose of 30 units on the pen. RN #713 then donned gloves. RN #713 entered Resident #5's room and RN #713 explained the procedure to Resident #5. Then RN #713 administered the insulin to Resident #5. RN #713 did not prime the Basalar Kwik pen prior to insulin administration to Resident #5. Interview with RN #713 on 11/15/23 at 7:20 A.M. confirmed after placing the needle on the Basalar Kwik pen, the nurse dialed the pen to the 30 unit dose ordered for Resident #5. RN #713 verified she did not prime the Basalar Kwik pen prior to insulin administration to Resident #5. Review of the policy titled Atrium Centers-Insulin Pen, last revised on 01/01/23, revealed it is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration. The policy explanation and Compliance Guidelines included insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Review of the manufacturer administration instructions for Basalar Kwik pen revealed to prime before each injection. Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select two units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with the Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to five slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than four times. If you still do not see insulin, change the Needle and repeat the priming steps. 366028 Page 14 of 14