Health inspection·August 26, 2021

F 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of the surety bond, trial balance funds sheet and staff interview the facility failed to provide a surety bond large enough to cover the total amount of money in all resident personal funds accounts. This affected 26 residents who currently had a resident funds account with the facility. The facility census was 39. Residents Affected - Some Findings include: Review of this facility's surety bond revealed it was in the amount of $35,000.00. Review of the resident trial balance funds documented the total money in the resident funds account totaled $46,104.68. Interview on 08/25/21 at 10:30 A.M. the Administrator verified the amount of monies in the resident funds account exceeded the amount of the surety bond. Page 1 of 4 366118 366118 08/26/2021 Elms Retirement Village Inc 136 S Main St Wellington, OH 44090

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 record review, interview and policy review, the facility failed to ensure the bowel regimen protocol was followed to prevent constipation. This affected one resident (Resident #7) of the three residents reviewed for incontinence care. The facility census was 39. Findings include: Review of the medical record for Resident #7 revealed an admission date of 10/25/18. Diagnosis included dementia with Lewy bodies, adult failure to thrive, insomnia, and encounter for palliative care. Review of the care plan dated 10/29/18 revealed she had potential for alteration in bowel elimination, constipation related to process and impaired mobility. Interventions included to assist with toileting as needed, record all stools, report irregularities to charge nurse, encourage fluid intakes as appropriate, note any signs or symptoms of constipation, monitor stool frequency, and follow bowel regimen protocol as needed. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. She required extensive assistance with two persons assist for bed mobility, transfers, dressing and toileting. She was always incontinent of bladder and frequently incontinent of bowel. Review of the physician orders dated August 2021 revealed Resident #7 had orders to give milk of magnesia, 30 milliliters (ml) by mouth as needed for constipation times one per episode. Bisacodyl suppository to insert one suppository rectally as needed for constipation times one per episode if milk of magnesia was ineffective. And Fleet Enema to insert one dose rectally as needed for constipation times two per episodes if bisacodyl suppository was ineffective. Call the physician if no bowel movement in four days. Review of the Point of Care task sheets revealed Resident #7 did not have a bowel movement from 07/28/21 through 08/04/21 and 08/09/21 through 08/13/21. Review of the Medication Administration Record (MAR) for July and August 2021 contained no documented evidence the resident received bisacodyl suppository, docusate, Milk of Magnesium or fleet enema for no bowel movement. Review of the nursing notes dated 07/27/21 through 08/25/21 revealed no notification was made to the physician of the resident not having a bowel movement. During interview on 08/25/21 at 9:45 A.M., State Tested Nursing Assistant (STNA) #42 stated bowel and bladder charting was done on every shift. If a resident has not had a bowel movement in three day the system will notify the nurse of no bowel movement. During interview on 08/25/21 at 9:40 A.M., Licensed Practical Nurse (LPN) #62 revealed the bowel protocol was to notify the physician after three days without a bowel movement. She stated they will start to give Milk of Magnesia and if that did not work then a suppository and notify the physician. 366118 Page 2 of 4 366118 08/26/2021 Elms Retirement Village Inc 136 S Main St Wellington, OH 44090

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She would document in the progress notes in the computer when she would notify the physician. She revealed if a resident had not had a bowl movement in the past three day the computer would have a notification show up, or the information would show on the look back report. During interview on 08/25/21 at 3:30 P.M., the Director of Nursing (DON) verified the resident did not have a bowel movement from 07/29/21 through 08/04/21 and 08/09/21 through 08/13/21. She further verified the orders were not followed and no medications were given to the resident during the same time frame. Review of the facility policy titled Bowel Protocol revealed residents would be assessed by nursing during admission, readmission, quarterly and significant change for bowel habits/patterning. Based on assessment of bowel habits/patterning the interdisciplinary team will develop comprehensive care plan as appropriate. Resident bowel movements will be monitored daily by during. Following recommended protocol may be instituted under the direction of the residents attending physician: resident that does not have a bowel movement after three days would receive Milk of Magnesia (MOM). If no results from MOM administer Bisacodyl suppository. If no results from Bisacodyl administer fleet enema. If no bowel movement occurs within four days, the nurse will notify the attending physician or certified nurse practitioner. 366118 Page 3 of 4 366118 08/26/2021 Elms Retirement Village Inc 136 S Main St Wellington, OH 44090

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 observation, record review, interview and manufacturer's recommendations, the facility failed to use distilled water in a continuous positive airway pressure (CPAP) machine. This affect one (Resident #29) of three residents reviewed for respiratory care. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #29 revealed an admission date of 06/19/21. Diagnosis included respiratory failure, diabetes mellitus type two, and chronic obstructive pulmonary disease. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. He used oxygen. Review of the nursing progress note dated 08/22/21 revealed Resident #29 refused to wear the CPAP machine during this evening as ordered. Resident stated he had incorrect water to use in the machine at this time and until the correct water was purchased he would not be wearing the CPAP machine. Nurse educated the resident and encouraged resident to follow orders, and the resident again refused. During interview on 08/23/21 at 4:40 P.M., Resident #29 stated the facility was giving him the wrong water to place in his CPAP machine. The resident held up a gallon of water, which was spring water. The CPAP machine reservoir had a milky film on the inside. He stated spring water was good to drink but not good to inhale. During interview on 08/25/21 at 9:40 A.M., Licensed Practical Nurse (LPN) #63 stated distilled water was supposed to be used in Resident #29's CPAP machine. She said the resident complained earlier in the week that he was given spring water to use instead of distilled water. During interview and observation on 08/25/21 at 10:00 A.M., Scheduler #46 stated staff were to use the distilled water for the CPAP machines, which was located in the kitchen dry stock area. She was unaware of any resident using spring water. Review of the manufacturer user guide revealed distilled water was to be used in the CPAP machine to reduce the risk of the equipment becoming mineralized. 366118 Page 4 of 4