Health inspection·January 26, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #41) of one resident reviewed for advanced directives. The facility census was 67. Findings include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, chronic kidney disease, generalized anxiety disorder, depression hyponatremia, hypokalemia, and iron deficiency anemia. Review of the signed documents section of Resident 41's medical record revealed a signed do not resuscitate comfort care- arrest (DNRCC-A) consent dated [DATE]. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #41 was cognitively intact and required extensive assistance with one-person physical assistance for activities of daily living. Review of Resident #41's care plan dated [DATE] revealed the resident was a DNRCC-A code status signifying that cardiopulmonary resuscitation (CPR) was not to be conducted in case of cardiac or respiratory arrest. Review of the [DATE] to [DATE] physician orders for Resident #41 revealed an ordered dated [DATE] for Full Code status signifying that CPR measures were to be conducted in case of cardiac or respiratory arrest. Observation on [DATE] at 8:14 A.M. revealed Resident # 41's physician's orders for [DATE] to [DATE] indicated the resident was a Full Code. The hard chart had a face sheet and on the stem of the hard chart was a sticker that indicated DNR-CCA. This was verified by Registered Nurse (RN) #203 on [DATE] at 8:20 A.M.; RN #203 stated that they should both match. Review of the facility policy dated 11/2022 titled, Residents' Rights Regarding Treatment and Advanced Directives revealed during the care planning process, the facility would identify, clarify, and review with the resident or legal representative whether they desired to make any changes related to any advanced directives. Any decision making regarding the resident's choices would be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Page 1 of 4 366135 366135 01/26/2023 Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219

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** 3. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia, nonexudative age-related macular degeneration, Rhabdomyolysis and nonrheumatic aortic valve stenosis. Residents Affected - Some Review of the quarterly MDS assessment dated [DATE] revealed Resident #61's cognition was intact. Resident #61 was independent with set up help only for personal hygiene and eating. Resident #61 utilized a walker for mobility assistance. Further review of the quarterly MDS assessment dated [DATE] indicated Resident #61 was on insulin. Review of Resident #61's physician's orders dated 05/12/22 revealed an order for Ozempic (hyperglycemic medication) 0.25 milligram (mg) subcutaneously every week on Tuesday. There was no order for the resident to receive insulin. Interview on 01/26/23 at 11:23 A.M. Director of Nursing #297 verified the Ozempic was coded on the MDS assessment as insulin. 4. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to encephalopathy, bipolar, metabolic syndrome, and diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #44's cognition was intact and the resident required extensive assistance with one staff for activities of daily living. Further review of the quarterly MDS assessment indicated Resident #44 was on insulin. Review of Resident #44's physician's orders dated 06/26/22 revealed an order for Trulicity (hyperglycemic medication) 0.5 milliliter (ml) subcutaneously every week on Saturday. There was no order for Resident #44 to receive insulin. Interview on 01/26/23 at 11:10 A.M. with MDS Licensed Practical Nurse (LPN) #309 verified that Trulicity was coded as insulin. 5. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified dementia, diabetes mellitus, unspecified psychosis, and Alzheimer's disease. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident required extensive assistance with one staff for activities of daily living except eating was coded for supervision with two staff. Interview on 01/26/23 at 8:11 A.M. with MDS Licensed Practical Nurse (LPN) #309 verified Resident #13 required one staff for supervision of eating, not two. Based on medical record review and staff interview, the facility failed to have accurate Minimum Data Set (MDS) assessments for four (Resident #3, #36, #44, and #61) of 10 residents who received injectable hyperglycemic medication and for one (Residents #13) of 20 residents whose records were reviewed that required assistance for eating. The census was 67. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted to the facility on 366135 Page 2 of 4 366135 01/26/2023 Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219

F 0641 Level of Harm - Minimal harm or potential for actual harm [DATE]. Diagnoses included displaced fracture of the second vertebra, major depression, high blood pressure, osteoarthritis, diabetes, and repeated falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3's cognition was intact. Resident #3 was independent with set up help only for bed mobility and eating. Resident #3 required extensive assistance of one staff member for dressing. The quarterly MDS assessment dated [DATE] also indicated Resident #3 was on insulin. Residents Affected - Some Review of the physicians orders dated 08/12/21 revealed an order for Ozempic (hyperglycemic medication)1 milligram (mg) every week on Thursday, Resident #3 did not receive insulin. Interview on 01/25/23 at 4:00 P.M. of Licensed Practical Nurse (LPN) #309 verified the Ozempic was coded on the MDS assessment as insulin. 2. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute embolism and thrombosis (05/11/21), diabetes and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #36's cognition was intact. Resident #36 was independent with set up help only for bed mobility and eating and supervision with one staff physical assistance for personal hygiene. Resident #36 received antidepressant and anticoagulant daily. Further review of the quarterly MDS assessment dated [DATE] indicated Resident #36 received insulin. Review of Resident #36's physicians orders dated 07/24/21 revealed an order for Ozempic 1 mg every Sunday. Interview on 01/25/23 at 4:00 P.M. of Licensed Practical Nurse (LPN) #309 verified the Ozempic was coded on the MDS assessment as insulin. 366135 Page 3 of 4 366135 01/26/2023 Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve food at the proper portion size to meet the nutritional needs of residents who received the alternate entrée. This affected two residents (#13 and #24) out of eleven (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119) who selected to receive a full portion of the alternate. The facility census was 67. Findings include: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified dementia, diabetes mellitus, unspecified psychosis, and Alzheimer's disease. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident required extensive assistance with one staff for activities of daily living. Review of the physicians' orders for January 2023 revealed Resident #13 was on a regular diet with no restrictions. Review of Resident #13's diet ticket revealed a five-ounce chicken Caesar wrap. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, diabetes mellitus, and major depressive disorder. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with one staff for activities of daily living and for meals required supervision for set up only. Review of the physicians' orders for January 2023 revealed Resident #24 was on a consistent carbohydrate no added salt diet. Review of Resident #24's diet ticket revealed a five-ounce chicken Caesar wrap. Observation of tray line on 01/25/23 at 11:40 A.M. revealed Resident # 13 and Resident #24 received a half portion (1/2) of a Caesar chicken wrap instead of the whole Caesar wrap (5 ounce) alternative which was identified on the meal ticket. Interview with [NAME] #277, at the time of the observation, revealed she has always served 1/2 of a wrap to residents. Interview on 01/25/23 at 11:43 A.M. with Registered Diet Technician (DTR) #289 verified Residents #13 and #24 should have been given a full Caesar wrap. Interview on 01/25/23 at 3:00 P.M. with DTR #289 revealed the following residents ordered full wrap sandwiches (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119). Residents #12 and #49 were to receive 1/2 portions of the chicken Caesar wrap. Interview on 01/26/23 at 8:24 A.M. with DTR #289 revealed the facility was having trouble printing recipes with the program and tray line was audited as needed for accuracy. 366135 Page 4 of 4