Health inspection·August 1, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, observations, and policy reviews, the facility failed to ensure the residents had a safe and homelike environment. This affected five residents (#36, #48, #54, #61, and #74). The facility census was 84. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 12/20/20. Diagnoses included hydrocephalus, schizoaffective disorder, seizures, [NAME] syndrome, and diabetes mellitus. Review of Resident #36's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Resident #36 required supervision and set up help only for all activities of daily living. The resident was not steady with walking, but able to stabilize without staff assistance. Review of the nursing note dated 06/26/23 revealed Resident #36 informed the nurses that the drop ceiling fell on her head when she was walking down the hallway. Resident #36 took a shower to clean up. The nursing assessment revealed no discolorations or bumps were observed on the resident. The resident's vital signs were within normal limits and neurological assessments were begun. The certified nurse practitioner (CNP) was contacted and a message was left with the guardian. The nursing note dated 06/27/23 revealed Resident #36 complained of head and neck pain. Per CNP orders, the resident was sent to the emergency room and evaluated related to the drop ceiling piece falling on her head last night. Review of Resident #36's emergency room report dated 06/27/23 revealed the resident reported to the emergency department with the chief complaint of a piece of ceiling tile falling onto her head. She reported that she was standing up, and the tile fell off hitting her head and landing on her left shoulder. She did not lose consciousness. She felt a little bit nauseous but denied vomiting. She stated that her left shoulder started to hurt more as well as her neck and denied taking anything for the pain. The physical exam of the resident was completely benign except for some limited range of motion of the left shoulder due to pain. The emergency room x-ray and scans of head, neck, and back were negative. The resident was discharged back to the facility with an order for Norco 5/325 milligrams. The diagnosis was cervical muscle strain and closed head injury without loss of consciousness. Review of the CNP's note dated 06/28/23 revealed the resident was sent to the emergency room yesterday following an incident where ceiling and ceiling fan fell on her head. She complained of head, neck, and shoulder pain. She was still sore in the left shoulder. The emergency room x-ray and scans Page 1 of 5 366067 366067 08/01/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0584 of head, neck, and back were negative. Diagnoses were a neck/shoulder/head pain and contusion. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #36 on 07/31/23 at 7:56 A.M. revealed she was walking in the hallway when a ceiling tile fell and hit her head and left shoulder. She went to the hospital. Residents Affected - Some Interview with Residents #48, #54, #61, and #74 on 07/31/23 and 08/01/23 revealed the ceiling tiles at the end of the 100 hall had been missing for approximately one month. Interview with Licensed Practical Nurse (LPN) #300, #301, #302, and State Tested Nursing Aides (STNA) #400, #401, and #402 on 07/31/23 between 8:05 A.M. and 11:10 A.M. verified Resident #36 did get injured when a saturated ceiling tile fell from the ceiling and hit her in the head and shoulder. They also confirmed the facility failed to replace the tile since the incident occurred. Interview with the Director of Nursing (DON) on 07/31/23 at 11:15 A.M. revealed a water saturated ceiling tile fell on Resident #36's head and neck. The resident was in pain, but received no fractures. A facility tour with the Maintenance Director #500 was completed on 07/31/23 between 8:15 A.M. and 8:32 A.M. Observations included a large opening of missing ceiling tile at the end of the 100 hall. Exposed were rolled insulation, plastic pipes, and heating ducts. The ceiling tiles measured approximately three feet by two feet. Interview with the Maintenance Director #500 on 07/31/23 at 8:20 A.M. revealed the air conditioning unit had a build up of condensation which made the ceiling tile wet. In turn, one of the ceiling tile fell on Resident #36's head. Both tile were then removed in which the condensation affected and failed to be replaced. 2. Review of Resident #48's medical record revealed an admission date of 01/01/22. Review of Resident #48's quarterly MDS assessment dated [DATE] revealed he had a high cognitive function and required a one-person assist for toilet use. Review of Resident #54's medical record revealed an admission date of 04/11/23. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed he had a large cognitive deficit and required supervision for toilet use. Review of Resident #61's medical record revealed an admission date of 08/05/22. Review of Resident #61's annual MDS assessment dated [DATE] revealed he had a high cognitive function and required supervision for toilet use. Review of Resident #74's medical record revealed an admission date of 01/23/23. Review of Resident #74's quarterly MDS assessment dated [DATE] revealed he had no cognitive impairment and was an extensive assist of one staff for toilet use. Tour with the Maintenance Director #500 on 07/31/23 at 8:30 A.M. revealed there were two resident rooms that shared one bathroom. There were four residents (#48, #54, #61, and #74) who shared the bathroom. There was no light in the bathroom that was shared amongst Residents #48, #54, #61, and #74. Inside the bathroom, there was a metal box hanging from the ceiling with a bare black wire extending out of the box. 366067 Page 2 of 5 366067 08/01/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0584 Level of Harm - Minimal harm or potential for actual harm Interview with the Maintenance Director #500 on 07/31/23 at 8:30 A.M. revealed on 07/02/23, the ceiling fan/light/exhaust caught on fire in the shared bathroom for Residents #48, #54, #61, and #74. The light had not been fixed since that time because the contractor was waiting for availability. Maintenance Director #500 verified the bathroom of Residents #48, #54, #61, and #74 did not have a light for the residents to use when they utilized the bathroom. Residents Affected - Some Interview with Residents #48, #54, #61, and #74 on 08/01/23 between 8:01 A.M. and 8:09 A.M. verified there was no light available in their bathroom. The residents stated they had to leave the door partially open when using the restroom and hoped it would be repaired soon. Review of the facility policy titled Maintenance Repairs/Work Orders, dated 08/2016, revealed it was the responsibility of the facility to ensure that facility's environment, equipment, and overall life safety is maintained to assist in prevention of breakdown. This deficiency represents non-compliance investigated under Complaint Number OH00145018. 366067 Page 3 of 5 366067 08/01/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to report an allegation of neglect of a resident to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #90) of three residents reviewed for abuse. The facility census was 84. Findings included: Review of the medical record for Resident #90 revealed an admission date of 03/02/21. Diagnoses included Alzheimer's disease, cardiomegaly, and anemia. Review of Resident #90's progress note dated 05/30/23 revealed the resident was lethargic with morning care. Her eyes were open to touch and name. Lung sound were clear with a scant amount of wheezing. Vital signs were within normal limits except for pulse oximetry (ox) reading which was 77%. Oxygen was applied via nasal cannula. On recheck her pulse ox was 95% at three liters per minute. Review of the facility's Self-Reported Incidents (SRI) from 05/30/23 through 07/30/23 revealed there was no allegation of neglect involving Resident #90 reported to the State Survey Agency, the Ohio Department of Health (ODH). Interview with the Director of Nursing (DON) on 07/31/23 at 11:07 A.M. revealed she received a complaint regarding Licensed Practical Nurse (LPN) #303 from a former State Tested Nursing Aide (STNA) #403 regarding care. The LPN was interviewed along with all of the STNAs who worked the night in question and found no concerns. The DON verified there was no SRI reported to ODH and stated there was no need for a SRI to be completed. Telephone interview with Former STNA #403 on 08/01/23 at 8:21 A.M. revealed at approximately 11:30 P.M. on 06/26/23 she informed LPN #303 that Resident #90 had a change in condition and was not feeling well. She again informed the nurse at approximately 1:30 A.M. on 06/27/23 and finally at 5:30 A.M. At approximately 6:00 A.M., LPN #303 went to assess Resident #90 and found the resident to have a low pulse ox reading and a rebreather had to be placed on the resident to increase her oxygen levels. Prior to leaving the facility that morning, Former STNA #403 filled out an incident report and placed it in the DON's mailbox on her door. Interview with the Administrator on 08/01/23 at 11:01 A.M. revealed she received a letter from a former STNA who quit recently. The Administrator stated the STNA (#403) informed her that one nurse on night shift neglected a resident. (#90) The Administrator investigated what she could and found no conclusions. The Administrator verified the facility did not submit an SRI to ODH. Review of the facility's undated policy titled Abuse Prohibition revealed residents will not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. Any reports or investigations will be reviewed by and conducted though the quality assurance (QA) committee. Neglect is a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All alleged violations concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/designee. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegations will be reported to the ODH with five (5) 366067 Page 4 of 5 366067 08/01/2023 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0609 working days of the incident. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00145018. Residents Affected - Few 366067 Page 5 of 5