Health inspection·January 16, 2024

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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, observations, resident interview, and staff interviews, the facility failed to ensure admission orders were obtained to provide care and treatment to a resident with a suprapubic urinary catheter. This affected one (#8) of one resident identified with a suprapubic catheter. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 01/01/24, with diagnoses including, gastroparesis, chronic obstructive pulmonary disease, infection, and inflammatory reaction due to indwelling urethral catheter, neuromuscular dysfunction of bladder, methicillin resistant staphylococcus aureus infection, colostomy, stage 4 pressure ulcer left buttock, sepsis, anemia, chronic respiratory failure, paraplegia, schizophrenia, bipolar disorder, major depressive disorder, and type 2 diabetes mellitus. Review of the minimum data set assessment dated [DATE], revealed Resident #8 was assessed with intact cognition, ability to make needs known, dependent on staff for the provision of activities of daily living, utilized an indwelling urinary catheter and colostomy, urinary tract infection last 30 days, and admitted with one stage 4 pressure ulcer. Review of the admission assessment dated [DATE] noted Resident #8 admitted from the hospital with a suprapubic urinary catheter in place. No documentation recorded the catheter stoma or insertion site. Further review of the medical record lacked physician orders or a nursing plan of care addressing the maintenance and treatment regarding the suprapubic catheter. Review of hospital discharge summary information dated 01/01/24 noted a pelvis pericystostomy wound with old drainage, cleansed with saline and dry dressing. wound length 1 centimeter (cm) by (x) 7 cm wide x 0.8 cm deep. Wound assessment recorded pink/red and bleeding, scant amount of moist serosanguinous drainage with fragile tissue to peri-wound. No physician treatment instructions were included in the discharge information. Review of physician orders from admission to 01/10/24 revealed no orders for the care and treatment of the suprapubic catheter or pericystostomy wound. Review of treatment administration records and medication administration records dated between 01/01/24 and 01/09/24 were silent to the treatment or care related to the suprapubic catheter or pericystostomy wound. Page 1 of 10 366039 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 01/10/24 at 6:00 A.M., observed Resident #8 alert and awake in bed. An indwelling urinary catheter bag was hanging from the bed frame and draining straw colored urine with sedimentation in the tubing. Interview at the time of the observation, Resident #8 stated the supra-pubic catheter insertion site had been draining since admission to the facility and the site had not been cleansed since the previous morning (01/09/24) during a shower. Resident #8 went on to state the suprapubic catheter had not been consistently cared for or cleansed since admission. Interview on 01/10/24 at 6:06 A.M., with LPN #200 revealed she had assumed care of Resident #8 on 01/09/24 at 6:45 P.M. until 01/10/24 at 7:15 A.M. LPN #200 stated she did not observe Resident #8 supra-pubic catheter site and was told by State Tested Nurse Aide (STNA) #400 catheter care was completed at an unspecified time. No report of the catheter or insertion site (stoma) was obtained. At 6:08 A.M., observation with LPN #200 during assessment of Resident #8 catheter stoma discovered a moderate amount of thick yellow/green purulent drainage, red tissue surrounding the site edges and tubing soiled. LPN #200 indicated the stoma site appeared without a dressing or treatment and lacked sufficient cleaning. LPN #200 proceeded to cleanse the site and Resident #8 displayed facial grimacing. Resident #8 reporting a pain level of 10 indicating severe pain. The resident again reported the catheter and insertion site had not been cared for since the previous morning during shower. Interview on 01/11/24 at 8:25 A.M., with Regional Registered Nurse (RRN) #1 during review of medical record confirmed Resident #8 admitted to facility on 01/01/24 with supra-pubic catheter. RNN #1 verified no physician orders or care plan were developed to address the care or treatment of the supra-pubic catheter stoma site. This deficiency represents non-compliance investigated under Complaint Number OH00149720. 366039 Page 2 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure wound treatments were applied as ordered by the physician. This affected one (#9) of three residents reviewed for the application of wound treatments. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 10/19/23, with the diagnoses including: acute respiratory failure, chronic coronary microvascular dysfunction, type 2 diabetes mellitus, dysphagia, hypertensive heart and chronic kidney disease, dementia, autoimmune hepatitis, and stage 3 pressure ulcer to right and left buttock. Review of the minimum data set assessment dated [DATE] assessed Resident #9 with intact cognition, required substantial or maximal assistance with activities of daily living, dependent on staff for bed mobility and transfer, frequently incontinent of bowel and bladder, and at risk for pressure ulcer development. Review of a nursing plan of care, revealed it was revised 12/11/23 to address Resident #9 actual alteration in skin integrity due to decreased mobility. Interventions included, complete daily monitoring pressure ulcer report, consult and treatment by Certified Wound Physician as needed, and follow physician orders for skin care and treatment. Review of physician orders noted on 12/27/23, the wound physician ordered a treatment to Resident #9 left buttock. Orders included cleanse wound with normal saline, apply medihoney to wound bed, cover with clean dry dressing complete every night shift every Tuesday, Thursday, Saturday for wound care. Review of Wound Physician #1 wound assessment documentation dated 01/02/24 noted the left buttock pressure injury assessed as unstageable with wound measurements 3.1 centimeters (cm) long by (x) 1.5 cm wide with a depth unable to be determined. Treatment order included cleanse wound with normal saline or sterile water, apply medical honey gel to wound bed and cover with dry clean dressing. Observation on 01/09/24 at 9:57 A.M., noted Licensed Practical Nurse (LPN) #201 remove Resident #9 incontinence brief and exposed the residents left buttock pressure ulcer. No dressing treatment was in place. LPN #201 was unaware the dressing was not applied as ordered. Additional observation noted Wound Physician #1 to assess and measure the wound. Measurements were 1.5 centimeters (cm) long by (x) 1.5 cm wide with a depth unable to be determined. The wound status was described as healing. Wound Physician #1 confirmed a dressing had been ordered and was to be applied to the left buttock pressure ulcer. Observation on 01/10/24 at 5:00 A.M., observed Resident #9 in bed, State Tested Nurse Aide (STNA) #404 removed Resident #9 incontinence brief and positioned the resident to the right. No dressing to the left buttock was in place. Interview with STNA #404 revealed she assumed Resident #9 care at 10:00 P.M. on 01/09/24 and checked the resident for incontinence every two hours. No dressing was applied, and she was instructed to apply zinc oxide cream. Interview on 01/10/24 at 5:06 A.M., with Registered Nurse (RN) #300 verified Resident #9 was to 366039 Page 3 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have a wound dressing covering the left buttock wound. RN #300 stated they assumed Resident #9 care at 6:45 P.M. on 01/09/24 and had not assessed the resident to ensure the dressing was applied. RN #300 was unaware the wound dressing was not in place as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00149720, and Complaint Number OH00149690. 366039 Page 4 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

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 observation, medical record review, staff and resident interview, and policy review, the facility failed to provide consistent care and treatment to a resident identified with a suprapubic catheter. This affected one (#8) of one resident identified with a suprapubic catheter. The facility census was 67. Findings include: Review of Resident #8's medical record revealed an admission date of 01/01/24 with diagnoses including, gastroparesis, chronic obstructive pulmonary disease, infection, and inflammatory reaction due to indwelling urethral catheter, neuromuscular dysfunction of bladder, methicillin resistant staphylococcus aureus infection, colostomy, stage 4 pressure ulcer left buttock, sepsis, anemia, chronic respiratory failure, paraplegia, schizophrenia, bipolar disorder, major depressive disorder, and type 2 diabetes mellitus. Review of the minimum data set assessment dated [DATE], revealed Resident #8 was assessed with intact cognition, ability to make needs known, dependent on staff for the provision of activities of daily living, utilized an indwelling urinary catheter and colostomy, urinary tract infection last 30 days, and admitted with one stage 4 pressure ulcer. Review of the admission assessment dated [DATE] noted Resident #8 admitted from the hospital with a suprapubic urinary catheter in place. No documentation recorded the catheter stoma or insertion site. Further review of the medical record lacked physician orders or a nursing plan of care addressing the maintenance and treatment regarding the suprapubic catheter. Review of the hospital discharge summary information dated 01/01/24 noted a pelvis pericystostomy wound with old drainage, cleansed with saline and dry dressing. The wound length was documented as 1 centimeter (cm) by (x) 7 cm wide x 0.8 cm deep. The wound assessment recorded pink/red and bleeding, scant amount of moist serosanguinous drainage with fragile tissue to peri-wound. No physician treatment instructions were included in the discharge information. Review of physician orders from admission to 01/10/24 revealed no orders for the care and treatment of the suprapubic catheter or pericystostomy wound. Review of treatment administration records and medication administration records dated between 01/01/24 and 01/09/24 lacked any evidence to the treatment or care related to the suprapubic catheter or pericystostomy wound. Review of skilled documentation dated 01/10/24 at 4:03 A.M. revealed Licensed Practical Nurse (LPN) #200 assessed Resident #8's abdomen as non-tender, continent of bowel and urine, with no catheter. Interview on 01/10/24 at 5:05 A.M., with State Tested Nurse Aide (STNA) #400 revealed she assumed care of Resident #8 on 01/09/24 at 10:00 P.M. until 01/10/24 at 6:00 A.M. STNA #400 stated she performed catheter care during the shift. STNA #400 was unable to describe the condition of the catheter insertion site or whether a dressing was applied to the site. Observation on 01/10/24 at 6:00 A.M. revealed Resident #8 was alert and awake in bed. An indwelling 366039 Page 5 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urinary catheter bag was hanging from the bed frame and draining straw colored urine with sedimentation in the tubing. Interview at the time of the observation Resident #8 stated the supra-pubic catheter insertion site had been draining since admission to the facility and the site had not been cleansed since the previous morning (01/09/24) during a shower. Resident #8 went on to state the suprapubic catheter had not been consistently cared for or cleansed since admission. Interview on 01/10/24 at 6:06 A.M. with LPN #200 revealed she had assumed care of Resident #8 on 01/09/24 at 6:45 P.M. until 01/10/24 at 7:15 A.M. LPN #200 stated she did not observe Resident #8's supra-pubic catheter site and was told by STNA #400 catheter care was completed at an unspecified time. No report of the catheter or insertion site (stoma) was obtained. At 6:08 A.M., observation with LPN #200 during assessment of Resident #8's catheter stoma discovered a moderate amount of thick yellow/green purulent drainage, red tissue surrounding the site edges and tubing soiled. LPN #200 indicated the stoma site appeared without a dressing or treatment and lacked sufficient cleaning. LPN #200 proceeded to cleanse the site and Resident #8 displayed facial grimacing. Resident #8 reported a pain level of 10 indicating severe pain. The resident again reported the catheter and insertion site had not been cared for since the previous morning during a shower. Review of general progress notes dated 01/10/24 at 7:52 A.M. documented during care it was noted resident has red area around suprapubic site. Area was assessed as red with moderate drainage, measuring 7.0 cm x 1.8 cm. Area cleaned with normal saline, zinc barrier cream and drain sponge applied. Wound physician updated and new treatment obtained. At 10:57 A.M., Resident #8 was complaining of chest pain and subsequently was sent to the hospital for evaluation. Review of hospital emergency room documentation dated 01/10/24, revealed Resident #8 was diagnosed with a urinary tract infection associated with cystostomy catheter. Interview on 01/11/24 at 8:25 A.M. with Regional Registered Nurse (RRN) #1 during review of the medical record confirmed Resident #8 admitted to the facility on [DATE] with supra-pubic catheter. RRN #1 verified no physician orders or care plan were developed to address the care or treatment of the supra-pubic catheter stoma site. RRN #1 verified the observation on 01/10/24 when Licensed Practical Nurse #200 assessed the stoma cite with moderate yellow/green drainage, peri wound red, soiled tubing and Resident #8 grimacing with slight manipulation of the tubing. Resident #8 reported a pain level of 10 indicating severe. Review of the policy titled, Supra Pubic Catheter: Guidance for Care, revised October 2022, revealed the skin around the catheter should be cleansed at least daily with warm water or warm soap and water and gently padded dry. If using soap rinse the area well to minimize irritation. Assess the skin for signs of irritation and possible infection: redness, drainage, and/or pain to the site. If noted, notify physician. This deficiency represents non-compliance investigated under Complaint Number OH00149720, OH00149860 and continued non-compliance from the 12/28/23 survey. 366039 Page 6 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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, staff interview, and laboratory contract review and policy review, the facility failed to obtain laboratory blood testing within physician ordered timeframes. This affected one (#6) of three sampled residents reviewed for laboratory blood testing. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 11/14/23, with the diagnoses including: acute kidney failure, chronic kidney disease stage 3, epilepsy, lupus, paraplegia, severe protein calorie malnutrition, hyperkalemia, metabolic acidosis, neuromuscular dysfunction of bladder, colostomy, pulmonary hypertension, anemia, and hypertension. Review of the minimum data set assessment dated [DATE] assessed Resident #6 with intact cognition, dependent on staff for the completion of activities of daily living, utilized an indwelling catheter and ostomy. Review of a physician order dated 01/01/24 at 5:15 P.M., revealed an order was initiated for STAT (immediately) laboratory (labs) to include a complete blood count (CBC) and basic metabolic profile (BMP). Review of the lab results dated as obtained on 01/02/24 at 8:01 A.M., Resident #6 was noted with a low hemoglobin (HGB) of 6.9 grams/deciliter (g/dL) with normal range 12.0-15.0 g/dL. No documentation contained in the medical record indicated the physician was informed of the results. Further review of the lab results noted the Certified Nurse Practitioner (CNP) #1 to initial the labs as reviewed on 01/04/24 with no time indicated. Review of a second lab test revealed it was obtained on 01/04/24 at 5:37 A.M. The results noted Resident #6 with a critical low HGB of 6.6 g/dL. No documentation indicated the physician was notified of the results. Review of nurses notes dated 01/04/24 at 5:55 P.M., documented Nurse Practitioner (CNP) #1 into see patient order to send to emergency room (ER). On 01/04/24 a late entry for 2:57 P.M., noted resident picked up by ambulance to transport to ER. Telephone interview on 01/10/24 at 2:41 P.M., with CNP #1 during review of documentation and laboratory values revealed labs were ordered STAT on 01/01/24. CNP #1 confirmed they did not receive communication of the lab results until 01/04/24 and Resident #6's HGB was low at 6.9 g/dL. CNP #1 reordered the lab and resulted in a critical HGB level of 6.6. Resident #6 was subsequently ordered to ER for evaluation and treatment of osteomyelitis. CNP #1 stated if the 01/02/24 lab results were received timely the resident would have been sent to the ER evaluation sooner on 01/01/24 due to concerns with health history. Interview on 01/10/23 at 2:56 P.M., the Director of Nursing (DON) confirmed the delay in receiving Resident #6 STAT labs on 01/01/24 and lack of communication with abnormal labs. Interview on 01/11/24 at 11:34 A.M., with Administrator during a review of laboratory documentation and policy confirmed when laboratory blood test is ordered as STAT, they are to be obtained within 366039 Page 7 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0770 4-5 hours. Level of Harm - Minimal harm or potential for actual harm Interview on 01/11/24 at 11:45 A.M., with Licensed Practical Nurse (LPN) #202 revealed when STAT labs are ordered the results should be reported back to the facility within 4 hours of specimen being obtained. Residents Affected - Few Review of facility laboratory services agreement signed 10/11/23, revealed testing ordered on an urgently sensitive basis (STAT Testing) incurs an additional fee of $45.00 per patient visit. STAT testing is based on the laboratory standard testing fee schedule set forth on Schedule I. Review of the undated policy titled Laboratory revealed STAT is defined as 4-5 hours. This deficiency represents non-compliance investigated under Complaint Number OH00149720. 366039 Page 8 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify physician timely of critical laboratory blood testing results. This affected one (#6) of three sampled residents reviewed for laboratory blood testing. The facility census was 67. Findings include: Review of Resident #6's medical record revealed an admission date of 11/14/23, with the diagnoses including: acute kidney failure, chronic kidney disease stage 3, epilepsy, lupus, paraplegia, severe protein calorie malnutrition, hyperkalemia, metabolic acidosis, neuromuscular dysfunction of bladder, colostomy, pulmonary hypertension, anemia, and hypertension. Review of the minimum data set assessment dated [DATE] assessed Resident #6 with intact cognition, dependent on staff for the completion of activities of daily living, utilized an indwelling catheter and ostomy. Review of a physician order dated 01/01/24 at 5:15 P.M., revealed an order was initiated for STAT (immediately) laboratory (labs) to include a complete blood count (CBC) and basic metabolic profile (BMP). Review of the lab results dated as obtained on 01/02/24 at 8:01 A.M., Resident #6 was noted with a low hemoglobin (HGB) of 6.9 grams/deciliter (g/dL) with normal range 12.0-15.0 g/dL. No documentation contained in the medical record indicated the physician was informed of the results. Further review of the lab results noted the Certified Nurse Practitioner (CNP) #1 to initial the labs as reviewed on 01/04/24 with no time indicated. Review of a second lab test revealed it was obtained on 01/04/24 at 5:37 A.M. The results noted Resident #6 with a critical low HGB of 6.6 g/dL. No documentation indicated the physician was notified of the results. Review of nurses notes dated 01/04/24 at 5:55 P.M., documented Nurse Practitioner (CNP) #1 into see patient order to send to emergency room (ER). On 01/04/24 a late entry for 2:57 P.M., noted resident picked up by ambulance to transport to ER. Telephone interview on 01/10/24 at 2:41 P.M., with CNP #1 during review of documentation and laboratory values revealed labs were ordered STAT on 01/01/24. CNP #1 confirmed they did not receive communication of the lab results until 01/04/24 and Resident #6's HGB was low at 6.9 g/dL. CNP #1 reordered the lab and resulted in a critical HGB level of 6.6. Resident #6 was subsequently ordered to ER for evaluation and treatment of osteomyelitis. CNP #1 stated if the 01/02/24 lab results were received timely the resident would have been sent to the ER evaluation sooner on 01/01/24 due to concerns with health history. Interview on 01/10/23 at 2:56 P.M., the Director of Nursing (DON) confirmed the delay in receiving Resident #6 STAT labs on 01/01/24 and lack of communication with abnormal labs. Interview on 01/11/24 at 11:45 A.M., with Licensed Practical Nurse (LPN) #202 revealed when STAT 366039 Page 9 of 10 366039 01/16/2024 Majestic Care of Point Place 6101 N Summit St Toledo, OH 43611

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few labs are ordered the results should be reported back to the facility within 4 hours of specimen being obtained. Review of policy tilted Notification of Change in Condition, revised 02/2022, indicated the purpose of the policy is to outline the actions of notification in timely manner to physician/physician extender in the event of a resident change in orders, acute situations, lab results, significant change in status, incidents that effect a residents status or transfer from the facility to hospital. This deficiency represents non-compliance investigated under Complaint Number OH00149720. 366039 Page 10 of 10