Health inspection·September 8, 2022

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. Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #40's advance directives were accurately reflected in the resident's medical record (the physician's orders and care plan were different). This affected one resident (#40) of one resident reviewed for advance directives. Findings include: Review of medical record for Resident #40 revealed an admission date of 09/30/21 with diagnoses including dementia, hypertension, spinal stenosis, and depression. Review of comprehensive care plan, dated 10/31/21 revealed Resident #40 wished to have her advanced directives honored as she was a Full Code. Review of a Do Not Resuscitate (DNR) form for Resident #40 located in her medical record revealed on 11/30/21 Primary Care Physician (PCP) #900 signed a DNR Comfort Care- Arrest advance directive form for the resident. No other DNR forms were noted in the resident's medical record. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/14/22 revealed Resident #40 was rarely or never understood. Review of the September 2022 physician's orders for Resident #40 revealed she had a DNR Comfort Care order dated 12/04/21, not a DNR Comfort Care- Arrest order. On 09/07/22 at 1:48 P.M. interview with the Director of Nursing (DON) revealed Resident #40 had a DNR form in her medical record that identified her advance directive status as DNR Comfort Care- Arrest. She indicated Resident #40's physician's orders identified Resident #40 as having a DNR Comfort Care was the DON indicated was inaccurate. The DON also verified Resident #40's care plan identified Resident #40 had a Full Code status which was also inaccurate. On 09/07/22 at 2:06 P.M. interview with the Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator verified the comprehensive care plan for Resident #40 was inaccurate as her advance directives should have been a DNR Comfort Care- Arrest not a Full Code. Review of facility policy titled Advance Directives Policy Statement, dated January 2015 revealed any changes of an advance directive must be submitted in writing to the Administrator and/or Director of Nursing who would submit the changes to the care plan team for adjustments to the resident's Minimum Data Set (MDS) and care plan. The policy also revealed the Director of Nursing and/or designee Page 1 of 10 366191 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0578 would notify the attending physician of the advance directives so that appropriate orders were documented in the medical record and care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366191 Page 2 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview the facility failed to notify Resident #43's representative in writing of a discharge to the hospital. This affected one resident (#43) of one resident reviewed for hospitalization. Findings include: Review of Resident #43's closed medical record revealed an initial admission date of 06/21/22 with diagnoses including hemiplegia/hemiparesis, gastrointestinal hemorrhage, anxiety, anemia, diabetes, hypertensive kidney disease, hyperlipidemia and gastrostomy. Review of a progress note indicated Resident #43 was discharged to the hospital on [DATE] for acute renal failure, gastrointestinal bleed and anemia. Resident #43 was then discharged from the hospital to a different facility closer to her family. Review of Resident #43's medical record revealed no evidence the resident's representative was provided in writing a transfer/discharge notice indicating the reasons for the discharge, the effective date of the discharge, the location where Resident #43 was sent, a statement of Resident #43's appeal rights, and the name/address/phone number of the Office of the State Long Term Care Ombudsman; all in writing and in a language and manner they understand. On 09/07/22 at 1:02 P.M. interview with the Director of Nursing (DON) and Business Office Manager #510 verified the facility did not notify the resident's representative of the discharge. The DON indicated the facility had not provided written discharge notices for any residents discharged from the facility in the last year. 366191 Page 3 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #34, who was identified as being at moderate risk for wandering/elopement had a care plan specifying this risk with individualized interventions. This affected one resident (#34) of one resident reviewed for wandering/elopement. Findings include: Review of the medical record for Resident #34 revealed an admission date of 04/08/22 with diagnoses including dementia, hypertension and hearing loss. Review of an admission Wandering Assessment, dated 04/08/22 and completed by Registered Nurse (RN) #502 revealed Resident #34 was at moderate risk for wandering. The assessment revealed Resident #34 was disoriented, forgetful, had a short attention span and she did not understand her surroundings. Review of the comprehensive care plan, with a date of initiation of 04/11/22 revealed Resident #34 did not have a care plan that identified Resident #34 the risk for wandering/elopement. Review of a quarterly Wander Assessment, dated 07/26/22 and completed by Licensed Practical Nurse (LPN) #536 revealed Resident #34 remained at moderate risk for wandering. The assessment revealed Resident #34 was forgetful, had a short attention span and did not understand what was being said due to cognition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/14/22 revealed Resident #34 was rarely or never understood. The assessment revealed the resident was non-ambulatory and required staff supervision with one-person physical assist for locomotion on and off the unit. This assessment indicated the resident had no wandering behaviors identified. Review of a nursing note, dated 08/25/22 at 7:04 P.M. and completed by LPN #528 revealed Resident #34 was exit seeking and confused. The nursing note revealed one on one (supervision) was effective. Review of a nursing note, dated 09/01/22 at 9:15 P.M. and completed by LPN #531 revealed Resident #34 was propelling all over the facility in her wheelchair continually asking everyone where her purse and shoes were. Review of a nursing note, dated 09/03/22 at 7:49 P.M. and completed by LPN #528 revealed Resident #34 was in her wheelchair wandering asking staff, do you see my shoes? and when staff attempted to redirect, resident cursed. Review of a nursing note, dated 09/05/22 at 4:04 P.M. and completed by LPN #528 revealed Resident #34 was exit seeking and wandering. The nursing note revealed Resident #34 was verbally aggressive and swearing at staff when redirected. On 09/07/22 at 1:27 P.M. and 3:23 P.M. Resident #34 was observed self-propelling her manual wheelchair throughout the facility including into the lobby area. On 09/07/22 at 2:06 P.M. interview with LPN/MDS Coordinator #523 verified on 04/08/22 and 7/26/22 366191 Page 4 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #34 was assessed at moderate risk for wandering. She also verified in the nursing notes on 08/25/22, 09/01/22, 09/03/22 and 09/05/22 Resident #34 was wandering and/or exit seeking. LPN/MDS Coordinator #523 verified the facility had not developed a comprehensive and individualized care plan for Resident #34's wandering and/or exit seeking behavior. Review of undated and untitled State Tested Nursing Aide (STNA) report sheet revealed Resident #34 was at risk for wandering. Review of an undated facility policy titled Elopement Policy and Procedure revealed confused residents that appear to have a tendency towards elopement would be targeted to wear a wander guard bracelet. The policy did not include anything regarding ensuring a care plan was initiated when a resident was assessed at moderate to high risk for wandering and/ or elopement. 366191 Page 5 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

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 record review, facility policy and procedure review and interview the facility failed to ensure fall risk assessments were completed timely following falls and failed to ensure fall care plan updates were completed timely to include all interventions in place. This affected three residents (#14, #20 and #39) of three residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and schizophrenia. Review of the assessments revealed on 12/30/21 a fall assessment was completed following a significant change in condition and Resident #39 was determined to be at high risk for falls. Review of the plan of care, dated 01/14/22 revealed Resident #39 was at risk for falls related to injuries. Interventions included one person assist for transfers with wheelchair, assess need for safety measures and fall interventions as needed (call light in reach, provide verbal reminders to call when needing assistance, place all personal items within reach). On 08/24/22 a care plan intervention included a pressure alarm to wheelchair as ordered and indicated to alert nursing of attempt to rise from chair. Review of the nursing progress notes dated 01/24/22 at 1:15 P.M. revealed a nurse was called to Resident #39's room and the resident was observed on the floor between the bed and his wheelchair. Vital signs were temperature 97.6; pulse 70; respirations 18; blood pressure 108/58; pulse oximetry was 94%; range of motion within normal limits, no injuries noted. Resident denied hitting his head. The physician was notified, pressure alarm was placed to wheelchair. The resident was assisted to bed with two person assistance. On 01/24/22 at 1:15 P.M., a nurse documented initiated neurological assessments; On 01/24/22 at 9:59 P.M. a nurse documented resident had no complaint of discomfort or pain from fall; On 01/25/22 at 12:42 P.M. a nurse documented the resident was alert and oriented, vital signs stable, no behaviors or complaints of pain or discomfort from previous fall. Chair alarm in place and functioning properly. On 01/26/22 at 4:45 P.M., a nurse documented the physician acknowledges notification of resident fall from wheelchair on 01/24/22. On 01/24/22, 01/25/22, 01/26/22 and 01/27/22 neurological assessments of Resident #39 were documented in the resident's records related to a fall. On 04/05/22 a quarterly fall assessment was completed and the resident was determined to be at a high risk for falls. On 04/06/22 at 11:54 P.M. a nurse documented a care plan meeting was held, resident declined attendance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/17/22 revealed Resident #39 had mild cognitive impairment. The assessment revealed Resident #39 required extensive one person assistance for bed mobility, transfers, toilet use and personal hygiene. The MDS also noted Resident #39 had no falls since admission. The resident was ordered an antidepressant and a diuretic medication. 366191 Page 6 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/02/22 at 12:55 A.M., a nurse documented being called to the resident's room and observing Resident #39 sitting on the floor next to the bed. Resident stated that he was trying to get up out of bed and get some clothes out of his drawer and his feet slid forward and he lowered himself down next to his bed and put his call light on for help. Resident said he did not hit his head and had no voiced complaints of pain. Range of motion and vital signs are all within normal limits for this resident. Blood pressure 134/74; temperature 97.8; pulse 76; respirations 18; pulse oximetry 96%. Resident was assisted up with two person assist back into bed and Neuro checks started. Physician notified and message left for the residents' family. Staffing will continue to monitor the resident. On 09/02/22, 09/03/22, 09/04/22 and 09/05/22 neurological assessments for Resident #39 were documented in the resident's records related a falls. Review of the physician's orders revealed one person assist with transfers with wheeled walker, occupational therapy consult, pressure alarm to wheelchair (initiated 01/24/22). The resident also received medications including Remeron, Hydrochlorothiazide, Metoprolol, Amlodipine, Losartan and Rivastigmine. On 09/07/22 at 3:45 P.M. interview with the Director of Nursing (DON) revealed there were no fall assessments completed for Resident #39 subsequent to the falls experienced on 01/24/22 and 09/02/22 and there should have been. The DON verified there should have been a fall assessment documented after the falls. The DON revealed staff performed a fall investigation on 01/24/22 with a recommendation for a seat alarm on the resident's wheelchair, but the recommendation for the seat alarm was not included with the resident's care plans until 08/24/22 and a fall investigation was completed on 09/02/22 with a referral to physical therapy for safe measures to independently obtain personal items. Review of the facility undated Fall Management policy revealed when a fall occurs with no injuries, the attending physician and family would be notified in an appropriate time frame, recommendations would be made and a safety nurse would follow through with an investigation. Review of the facility undated Fall Prevention Policy revealed upon admission and quarterly in correlation with the Minimum Data Set (MDS) assessment, a falls assessment would be completed on the resident with a fall risk score. 2. Review of medical record for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, heart failure, and hypertension. Review of the plan of care, dated 04/08/22 revealed Resident #20 was at risk for falls related to previous falls. Interventions included one person assist with front wheeled walker for transfers and gait, assess need for safety measures, fall interventions as needed, call light in reach, provide verbal reminders to call for assistance when needed. Review of the fall assessment, dated 04/08/22 revealed Resident #20 was at moderate risk for falls. On 05/21/22, 05/22/22, 05/23/22 and 05/24/22 neurological assessments were documented subsequent to a resident fall. Review of a nurse progress note, dated 05/21/22 at 5:45 P.M. revealed a nurse documented Resident #20 was observed sitting on the floor on his bathroom with his feet towards commode. Resident stated after toileting, he was trying to adjust his pants and slid out of the wheelchair onto his buttocks. Back brace in place. Denies pain or injury. Resident was returned to bed with two person assistance 366191 Page 7 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0689 and family was notified. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/21/22 revealed the resident had intact cognition and required limited one person assistance for bed mobility, extensive two person assistance for transfers and toilet use and extensive one person assistance for dressing and personal hygiene. The assessment revealed Resident #20 was always continent of bowel and bladder and was prescribed an antidepressant and an anticoagulant. Residents Affected - Few Review of the physician's orders revealed the resident required one assist with front wheeled walker for transfer and gait, up in wheelchair daily, bilateral grab bars up at all times when in bed and received the medications Cymbalta and Eliquis. On 09/07/22 at 3:45 P.M. interview with the Director of Nursing (DON) revealed there were no fall assessments completed for Resident #20 subsequent to the fall experienced on 05/21/22 and there should have been. The DON verified there should have been a fall assessment documented after the falls. Review of the facility undated Fall Management policy revealed when a fall occurs with no injuries, the attending physician and family would be notified in an appropriate time frame, recommendations would be made and a safety nurse would follow through with an investigation. Review of the facility undated Fall Prevention Policy revealed upon admission and quarterly in correlation with the Minimum Data Set (MDS) assessment, a falls assessment would be completed on the resident with a fall risk score. 3. Review of medical record for Resident #14 revealed an admission date of 06/24/22 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, type two diabetes mellitus and chronic kidney disease. Review of the resident assessments revealed on 06/24/22 a fall assessment revealed Resident #14 was at high risk for falls. Review of care plan, dated 06/27/22 revealed the resident was at risk for falls. Interventions included two person assist for transfers, call light in reach, provide verbal reminders to call for assistance and personal alarm to wheelchair at all times and check for function. Review of the quarterly MDS 3.0 assessment, dated 07/04/22 revealed the resident had moderate cognitive impairment and required extensive two person assist for bed mobility, toilet use and transfers and extensive one person assist for dressing and personal hygiene. The assessment revealed Resident #14 was also always incontinent of bowel and bladder and received insulin injections and a diuretic medication. Review of a nursing progress notes revealed on 07/09/22 at 3:54 P.M. a nurse documented Resident #14 was observed lying on the floor on the left side of the bed, call light was in reach and the floor was clean and dry. The resident was wearing hard soled slippers and the wheelchair was in close proximity at the time of the incident. The resident's call light was on and he was last observed by staff 15 minutes prior to the fall sitting in his wheelchair and using the telephone. Resident stated he was trying to get into bed. Resident denied pain and had no visible signs of injuries On 07/09/22, 07/10/22, 07/12/22 and 07/13/22 neurological assessments were completed for the 366191 Page 8 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0689 resident subsequent to a fall. Level of Harm - Minimal harm or potential for actual harm On 08/25/22 at 8:02 P.M. a nurse documented Resident #14 was observed sitting on the floor in front of his wheelchair. The resident stated he was trying to scoot back in the chair and it was not locked and he slid to the floor. The resident stated he did not hit his head, nor have any pain. Vital signs for the resident were within normal limits for the resident and range of motion was within normal limits. Residents Affected - Few On 08/25/22, 08/26/22, 08/27/22 and 08/28/22 neurological assessments were completed for the resident subsequent to a fall. Review of the resident's physician's orders revealed an order for personal alarm to wheelchair at all times, two person assist with wheeled walker for transfer, up in wheelchair as tolerated. The resident had medication orders that included Glargine insulin, Lasix and Clopidogrel. On 09/07/22 at 3:45 P.M. interview with the DON revealed there were no fall assessments completed for Resident #14 following the falls on 07/09/22 or 08/25/22 and there should have been. The DON verified there should have been a fall assessment documented after the falls. Review of the facility undated Fall Management policy revealed when a fall occurs with no injuries, the attending physician and family would be notified in an appropriate time frame, recommendations would be made and a safety nurse would follow through with an investigation. Review of the facility undated Fall Prevention Policy revealed upon admission and quarterly in correlation with the Minimum Data Set (MDS) assessment, a falls assessment would be completed on the resident with a fall risk score. 366191 Page 9 of 10 366191 09/08/2022 Maplecrest Nursing and Hta 400 Sexton Street Struthers, OH 44471

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide single rooms with at least 100 square feet of living space in each room. This affected six residents (#11, #14, #22, #29, and #30) of 44 residents residing in the facility. Findings include: On 09/06/22 at 9:42 A.M. interview with the Administrator revealed the facility had six single rooms with less than the required 100 square footage of living space. Five of the six rooms were occupied by residents at the time of the survey. Review of the space/occupancy certification waiver applications revealed Resident #11, #14, #22, #29, and #30 were in single rooms that measured less than the required 100 square feet of living space. The room measurements and residents affected were as follows: room [ROOM NUMBER] (Resident #30) 96.47 square feet. room [ROOM NUMBER] (Resident #14) 93.15 square feet. room [ROOM NUMBER] (Resident #11) 96.46 square feet. room [ROOM NUMBER] (Resident #22) 93.55 square feet. room [ROOM NUMBER] (vacant) 97.75 square feet. room [ROOM NUMBER] (Resident #29) 91.50 square feet. 366191 Page 10 of 10