Health inspection·March 21, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to accurately complete an updated pre-admission screening and resident review (PASARR) for residents with a diagnosis change. This affected one (#27) of three residents reviewed for PASARR. The facility census was 83. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Review of the physician order dated 03/15/24 revealed Resident #27 was ordered Risperdal 0.5 milligrams (mg), give one tablet by mouth two times a day for depression. Review of the physician order dated 03/15/24 revealed Resident #27 was ordered Zoloft 50 mg, give one tablet by mouth one time a day for depression. Review of the PASARR dated 09/04/19 for Resident #27 was the most current PASARR. The PASARR was not updated after new mental health diagnoses. Interview on 03/20/24 at 3:39 P.M., with the Administrator verified Resident #27's PASARR was not updated after a diagnosis change. Review of the policy titled, Admissions - From Other Healthcare Facilities, dated March 2017, revealed residents from other healthcare facilities may be admitted upon receipt of appropriate documentation including the PASARR. Page 1 of 4 366156 366156 03/21/2024 Lincoln Crawford Care Center 1346 Lincoln Avenue Cincinnati, OH 45206

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences as required. This affected two residents (#27 and #58) of 24 residents reviewed. The facility census was 83. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Review of the medical record for Resident #27 revealed a care conference had been completed on 07/12/23, 01/04/24, and 02/28/24 for the last 12 months. Interview on 03/21/24 at 10:44 A.M., with Social Services Director (SSD) #23 verified Resident #27 did not have regular quarterly care conferences for the last 12 months. 2. Review of the medical record for Resident #58 revealed an admission date of 01/29/21. Diagnoses included sepsis, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require setup for eating, supervision with toileting and dressing, substantial assistance with bathing, and partial assistance with transfers. Review of the medical record for Resident #58 revealed a care conference had been completed on 09/25/23, 02/09/24, and 02/24/24 for the last 12 months. Interview on 03/21/24 at 10:39 A.M. with SSD #23 verified Resident #58 did not have regular quarterly care conferences for the last 12 months. Review of the policy titled, Care Planning - Interdisciplinary Team, dated March 2022, revealed the interdisciplinary team was responsible for the development of resident care plans. Care plan meetings were scheduled at the best time of the day for the resident and family when possible. 366156 Page 2 of 4 366156 03/21/2024 Lincoln Crawford Care Center 1346 Lincoln Avenue Cincinnati, OH 45206

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interviews, and policy review, the facility failed to ensure a safe, clean, and home-like environment. This affected two (#2 and #27) of 24 residents reviewed for environment. The facility census was 83. Findings include: 1. Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with other diabetic kidney complication, other sequelae of cerebral infarction, chronic kidney disease stage three, schizophrenia, morbid obesity due to excess calories, major depressive disorder, neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, cerebral ischemia, hyperlipidemia, and dysphagia following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/11/24, revealed this resident had severely impaired cognition. This resident was assessed to require moderate assistance with eating and oral hygiene, maximal assistance with bed mobility, and was dependent on staff for dressing, personal hygiene, transfer, toileting, and bathing. Observation on 03/21/24 at 11:50 A.M., revealed there was a vertical gash with missing drywall and chipped paint in the wall near the baseboard behind the head of Resident #2's bed, which was visible when standing next to the bed. Interview on 03/21/24 at 12:00 P.M., with Licensed Practical Nurse (LPN) #11 confirmed the gash in the wall in Resident #2's room. 2. Review of the medical record for Resident #27 revealed an admission date of 08/05/19. Diagnoses included progressive multifocal leukoencephalopathy (PML), parkinson's disease, major depressive disorder, bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require supervision with toileting and transfers, and partial assistance with bathing and dressing. Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's bed sheets had scattered brown substance at the head of the bed. Observations throughout the annual survey (03/18/24 - 03/21/24) revealed Resident #27's wall behind her bed had scattered brownish-orange substance on the wall and the overhead light. The substance was scattered from the head of the bed to the foot of the bed. Interview on 03/21/24 at 11:44 A.M., with State Tested Nurses Aide (STNA) #33 verified the sheets were soiled and the wall and overhead light had a substance scattered on the wall and light. Review of the policy titled, Quality of Life - Homelike Environment, dated May 2017, revealed 366156 Page 3 of 4 366156 03/21/2024 Lincoln Crawford Care Center 1346 Lincoln Avenue Cincinnati, OH 45206

F 0921 resident were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366156 Page 4 of 4