Health inspection·June 15, 2021

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview the facility failed to ensure a resident was turned safely while in bed during incontinence care and failed to ensure there were two staff members present during the incontinence care. This affected one (#38) of three reviewed for incontinence care. The facility identified nine residents who were incontinent. The facility census was 42. Findings included Medical record review for Resident #38 revealed an admission date of 05/26/17. Medical diagnoses included coronary artery disease, heart failure, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. Her functional status was extensive assistance with two-person assistance for bed mobility, total dependence for transfers with two-person assistance, eating with extensive assistance one-person assistance, and toilet use was total dependence with two-person assistance. She was always incontinent for bladder and bowels. Review of the care plan dated 05/31/21 revealed she was at risk for incontinence for bowel and bladder. There was no intervention for two-person assistance for changing the resident. Observation of incontinence care for Resident #38 on 06/10/21 at 9:40 A.M. revealed the resident had large fall mats to both sides of the bed and was totally dependent for care. During the care the State Tested Nursing Aide (STNA) #46 rolled the resident away from her to the edge of the left side of the bed while the STNA stood on the right side of the bed and proceeded to clean the buttocks and rectum. The STNA proceeded with the care and the resident rolled back onto her back and the STNA rolled the resident away from her again and proceeded to finish with cleaning the rectum and buttocks. The surveyor intervened and asked why she rolled the resident away from her during the incontinence care revealed because the resident had a perimeter mattress on the bed she rolled her away from her, but the other residents who didn't have a perimeter mattress she would roll them towards her. At the end of the care when she was putting the adult brief on the resident, she rolled the resident toward her to finish the task. During the care the resident had not participated in any commands and had not helped with the care. Interview with STNA #46 on 06/10/21 at 9:56 A.M. revealed she had not had another person help her because the resident was a one-person assistance for changing. She felt comfortable doing the care by herself because she had a perimeter mattress and thought she could do this. Page 1 of 7 366142 366142 06/15/2021 Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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, resident and staff interviews, observations, and review of the dialysis communication form, the facility failed to timely address recommendations from the dialysis physician. This affected one resident (#05) of one resident who received dialysis treatment. The facility census was 42. Residents Affected - Few Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included end stage kidney failure, cellulitis of the left limb, atrial fibrillation, and hypertension. A care plan relative to psychological and medical needs revealed individualized interventions with measurable goals. Review of the physician orders for June 1, 2021 to June 08, 2021 revealed the resident continued on a 1500 cubic centimeter (cc) fluid restriction. Review of the verbal physician orders from 06/01/21 to 06/08/21 confirmed a new order was not obtained to decrease Resident #05's fluid intake as ordered by the dialysis physician. Observation on 06/09/21 at 9:00 A.M. of Resident #05's breakfast tray revealed a meal ticket indicating the resident was on a 1500 cc fluid restriction diet. Observation on 06/10/21 at 4:45 P.M. of Resident #05's dinner tray revealed a meal ticket indicating the resident was on a 1500 cc fluid restriction diet. Interview on 06/09/21 at 9:10 A.M., the Resident #05 verified she continued following a 1500 cc fluid restriction diet. She denied knowing anything about changing the fluid restriction to 1200 cc's. Interview on 06/10/21 at 12:15 P.M., the Licensed Practical Nurse (LPN) #74 verified the dietician or the physician was notified of the follow-up orders from the dialysis physician on 06/03/21. Resident #05 continued on a 1500 cc fluid restriction diet. The dietician should have been notified immediately about the dialysis orders so this could have been presented to the physician and discussed the new recommendations for the resident. Review of the Care Center Dialysis Communication form revealed on 06/03/21 Resident #05 returned from dialysis with follow up orders that read needs to have fluid restriction of 1200 cc per day was gaining 4 to 6 kilograms (kg) between treatments and should be more around 1.5 to 2 kg. 366142 Page 2 of 7 366142 06/15/2021 Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and review of the pharmacy recommendations, the facility failed to ensure a resident was free from unnecessary medication use. This had the potential to effect one resident (#46) of five residents reviewed for unnecessary medications. The facility census was 42. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included fractured right-side ribs, dementia, anxiety disorder, respiratory failure, and malnutrition. Review of Resident #46's care plan revealed the resident received rehabilitation services with a goal to be discharged home. Further review of the the plan of care dated 05/14/21 revealed no plan for psychosis behaviors. Review of the monthly physician orders dated May 2021 revealed Resident #46 was ordered Risperdal (an antipsychotic medication) two milligram (mg) one tablet by mouth daily for anxiety. Review of the monthly physician orders dated June 2021 revealed Resident #46 was ordered Risperdal two mg one tablet by mouth daily for psychosis. Review of Resident #46 diagnosis sheet revealed no active diagnosis for the use of an antipsychotic. Interview on 06/07/21 at 5:00 P.M., the Resident #46 revealed he was kind, very friendly, and answered questions appropriately. There was no indication the resident was confused or anxious at this time. Interview on 06/07/21 at 5:10 P.M., the Licensed Practical Nurse (LPN) #64 revealed Resident #46 was very friendly and displayed no behaviors. Interview on 06/10/21 at 11:00 A.M., the Director of Nursing (DON) revealed Resident #46 was given Risperdal in the hospital and should not be taking the drug while in the facility. He had no behaviors to support the use of an antipsychotic medication. Review of the Pharmacist recommendation dated 06/01/21 indicated the resident had no diagnosis for the use of the medication Risperdal. 366142 Page 3 of 7 366142 06/15/2021 Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, review of the dietary spread sheets, and review of the diet manual, the facility failed to ensure residents on a mechanical soft diet were served food of an appropriate texture. This affected two residents (#07 and #25) of seven residents who received a mechanical soft diet. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #07 revealed an admission date of 06/11/20. Diagnoses included psychotic disorder with delusions, dysphagia, and senile degeneration of the brain. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #07 had severely impaired cognitive skills for daily decision making and required supervision assistance with eating and extensive to total dependence assistance with all other activities of daily living. Review of the active physician orders revealed an order dated 06/11/20 for mechanical soft diet with nectar thickened liquids. Observation of the dinner meal service on 06/09/21 between 4:35 P.M. and 4:50 P.M., revealed Chef #66 served Resident #07 garlic toast with her dinner meal. Resident #07's meal was then loaded onto the delivery cart and taken to the hall to be delivered to Resident #07. Interview with the Regional Dietitian #72 on 06/09/21 at 4:51 P.M., revealed residents on a mechanical soft diet should receive bread with choice margarine in place of garlic toast. The interview verified Resident #07 should not have been sent garlic toast on her dinner meal tray. 2. Review of the medical record for Resident #25 revealed an admission date of 03/23/17. Diagnoses included Alzheimer's disease, gastro-esophageal reflux disease, and chronic obstructive pulmonary disease. Review of the annual MDS dated [DATE] revealed Resident #25 was severely cognitively impaired and required supervision assistance with eating and extensive assistance with all other activities of daily living. Review of the active physician orders revealed an order dated 04/30/20 for a mechanical soft diet with thin liquids. Observation of the dinner meal service on 06/09/21 between 4:35 P.M. and 4:50 P.M., revealed Chef #66 served Resident #25 garlic toast with her dinner meal. Resident #25's meal was then loaded onto the delivery cart and taken to the hall to be delivered to Resident #25. Interview with Regional Dietitian #72 on 06/09/21 at 4:51 P.M. revealed residents on a mechanical soft diet should receive bread with choice margarine in place of garlic toast. The interview verified Resident #25 should not have been sent garlic toast on her dinner meal tray. Review of the dietary spreadsheet for the dinner meal on 06/09/21 revealed bread with choice 366142 Page 4 of 7 366142 06/15/2021 Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026

F 0805 margarine was marked in place of garlic toast for residents on a mechanical soft diet. Level of Harm - Minimal harm or potential for actual harm Review of the facility diet manual titled Soft Diet, undated, revealed the following grains should be avoided: dry breads, toast, crackers, tough thick crusty breads such as baguettes or french bread, dry bread dressing, bread with seeds/nuts, course or dry cereals such as shredded wheat or bran flakes, and dry cakes or cookies that are chewy or very dry. Residents Affected - Few 366142 Page 5 of 7 366142 06/15/2021 Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, review of the infection control logs, and policy review, the facility failed to maintain appropriate infection control measures to prevent the spread of COVID-19. This had the potential to affect all residents who reside in the facility. The facility census was 42. Residents Affected - Many 1. Observation and interview on 06/07/21 at 8:00 A.M., upon entrance to the facility, Licensed Practical Nurse (LPN) #05 walked through the reception area after completing nasal swab testing wearing a yellow gown. LPN #05 was not noted to change her personal protective equipment (PPE). This was verified with the Regional Business Officer #80 the LPN was wearing PPE through the reception area while testing staff. 2. Observation and interview on 06/07/21 at 11:16 A.M., with LPN # 64 verified the quarantine area entry doors were open and resident room doors were open. 3. Observation and interview on 06/07/21 at 11:16 A.M. revealed the quarantine unit did not have PPE located in the hallway or near the door of each resident's room. All PPE was located inside the resident's room. Observation of the Unit Manager #40 entered Resident #37's room with no PPE on, and closed the door. When the Unit Manger completed care, she opened the door, removed her PPE and walked through the residents room to the resident's bathroom on the other side of the room to wash her hands, and then walked back through Resident #37's room to the door without PPE on. Interview with the Unit Manager #40 at the time of the observation verified the PPE for all residents was located inside their room. She further verified she took her PPE off and then went to the restroom to wash her hands and walked through Resident #37's room with no PPE on except for an N-95 mask and goggles. 4. Observation on 06/07/21 at 11:30 A.M. of the COVID unit revealed no signage delineating the COVID unit. Interview on 06/07/21 at 12:22 P.M. with the Regional Nurse #70 verified there was no signage on the COVID unit. Interview on 06/07/21 at 2:30 P.M. with Regional Nurse #70 verified signage was placed on the COVID unit. Review of the infection control logs dated 03/2021 through 06/01/21 revealed 05/18/21 through 05/27/21 the facility had 14 positive COVID cases. Review of facility policy titled Transmission-Based Precautions: Contact Precautions reviewed on 12/29/20, revealed the facility must put on gloves, and gowns on before room entry and discard gloves and gowns before exiting the room. Review of the facility policy title Transmission-Based Precautions: Airborne Precautions reviewed 12/29/20, revealed the facility must keep the room doors closed and the patient/resident in the room provided, and respiratory protection for all visitors and staff must be worn when entering rooms. Place a sign on the door of the patient/resident's room and instruct visitors to report to Nurse prior to entering. Signage on the door states Airborne Precautions. Everyone must: clean their hands, including before entering and when leaving the room, put on a fit-tested N-95 or higher level respirator before room entry, remove respirator after exiting the room and close the door, and door to the room must remain closed. 366142 Page 6 of 7 366142 06/15/2021 Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility policy titled Resident and Staff COVID-19 Screening Process and Initial Reporting Process, reviewed 05/12/21 revealed standard procedures included contact and droplet precautions would be followed for any patients/residents suspected or confirmed to have COVID-29 per the director of the public health department. At present and under an abundance of caution, the Center for Disease Control (CDC) was recommending healthcare facilities use Standard Precautions, Contact Precautions, Airborne Precautions, and Eye Protections. This means wearing a gown, gloves, N-95 and goggles. This deficiency substantiates Master Complaint Number OH00122875, Complaint Number OH00112029, Complaint Number OH00111393, and Complaint Number OH00111297. 366142 Page 7 of 7