Health inspection·September 9, 2021

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure personal hygiene in the form of showers was completed as scheduled for residents unable to complete showers independently. This affected two (Resident #2 and Resident #27) of three residents reviewed for showers. The facility census was 27. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 08/20/20. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), dyspnea, unspecified dementia without behavioral disturbance, major depressive disorder, osteoarthritis, unspecified rotator cuff tear or rupture of right shoulder, anxiety disorder, schizoaffective disorder, Bipolar disorder, and weakness. The Annual Minimum Data Set (MDS) on 08/25/21 revealed Resident #2 had moderately impaired cognition and was totally dependent on staff for assistance with bathing. Review of the plan of care for Resident #2 revised 05/18/21 revealed the resident had impaired Activity of Daily Living (ADL) function and required assistance to perform/complete ADL's. Goals for the resident included: provide nail care and shampoo hair with showers per weekly schedule, groom hair daily and encourage resident to participate as able, provide assistance with morning and afternoon care, encourage resident to participate with hygiene as tolerated, assist with and/or shave facial hairs daily as needed or per resident preference. Review of shower logs from 07/01/21 through 08/30/21 revealed from 07/05/21 to 08/05/21, Resident #2 only received either an other bath or a partial bed bath. The resident received a complete bed bath on 08/05/21. From 08/09/21 to 08/18/21, there were no documented showers or bed baths completed. On 08/18/21, Resident #2 refused a shower. From 08/18/21 to 08/30/21, there were no documented showers or bed baths completed. Interview on 09/07/21 at 11:09 A.M. with Resident #2 revealed the resident had not received a shower in three weeks until yesterday, 09/06/21. The resident stated he did refuse a shower or a bed bath sometimes but that was because the staff offered to assist him when it was too late in the day. Interview on 09/09/21 at 2:30 P.M. with the Director Of Nursing (DON) confirmed residents are scheduled for showers or bed baths at least twice a week. The other bath did not include washing Resident #2's hair or completing nail care. The aide washed the resident up while he was in the bathroom. The DON confirmed there was no documentation the resident received a complete bed bath or shower from 07/05/21 through 08/05/21 or from 08/09/21 through 08/30/21. Page 1 of 6 366196 366196 09/09/2021 Altercare Newark South Inc. 17 Forry Street Newark, OH 43055

F 0677 Level of Harm - Minimal harm or potential for actual harm 2. Review of the closed medical record for Resident #27 revealed an admission date on 07/30/21 and a discharge date on 08/22/21. Medical diagnoses included encephalopathy, muscle weakness, unspecified dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), unspecified rotator cuff tear or rupture of left shoulder, abdominal aortic aneurysm, and Type II Diabetes mellitus without complications. Residents Affected - Few The admission MDS 3.0 assessment, dated 08/05/21, revealed Resident #27 had moderately impaired cognition and required extensive assistance from one staff person to complete bathing. Review of the plan of care for Resident #27 dated 08/02/21 revealed the resident had a self-care deficit due to medical diagnoses including encephalopathy, diabetes, COPD, history of carotid artery surgery, pacemaker, and abdominal aneurysm repair and mental health diagnoses including forgetfulness, annoyance, and frustration. Interventions included allow as much independence with Activities of Daily Living (ADLs) as possible while still maintaining safety, provide encouragement as needed to participate with ADLs daily and offer praise for resident's efforts, provide assistance as needed with ADLs. Review of shower logs dated from 07/30/21 to 08/21/21 revealed there was no documentation Resident #27 had received a shower or a complete bed bath from 07/30/21 to 08/06/21 or from 08/08/21 to 08/14/21. Interview on 09/09/21 at 2:30 P.M. with the Director Of Nursing (DON) confirmed residents are scheduled for showers or bed baths at least twice a week. The DON stated the facility was using agency staff frequently and accurate documentation had been an issue. The DON confirmed there was no documentation showing Resident #27 had received a shower or bed bath from 07/30/21 to 08/06/21 or 08/08/21 to 08/14/21. The DON stated the facility did not have a policy related to providing ADLs for dependent residents or showers/bathing. This deficiency substantiates Master Complaint Number OH00125518 and Complaint Number OH00125449. 366196 Page 2 of 6 366196 09/09/2021 Altercare Newark South Inc. 17 Forry Street Newark, OH 43055

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. Based on observation, medical record review, staff interview, and review of facility policy and procedure, the facility failed to ensure appropriate fall interventions were in place. This affected one resident (Resident #7) out of four residents reviewed for falls. The census was 27. Findings Include: Review of the medical record for Resident #7 revealed an admission date of 05/17/17 and the diagnoses of cachexia, spinal stenosis, dementia, anxiety, high blood pressure, chronic kidney disease stage 3, vitamin D deficiency, osteoporosis, peripheral vascular disease, depression, muscle weakness, contractures, insomnia, peptic ulcer disease. Review of the Minimum Data Set (MDS) assessment, dated 06/10/21, revealed the resident had a Brief Interview of Mental Status (BIMS) of 04 indicating impaired cognition and she required extensive assistance of one staff for bed mobility. Review of the care plan dated 06/02/18 revealed the resident was at risk for falls or injuries related to behaviors, confusion, altered mental status, incontinence, and medications with interventions for bilateral floor mats when in bed and low bed when occupied. Observation on 09/07/21 at 11:00 A.M., on 09/08/21 at 3:34 P.M. and on 09/09/21 at 7:51 A.M. revealed Resident #7 had a half sized fall mat to the top right side of her bed and a half sized floor mat to the lower left side of her bed. There were no floor mat protections to the lower right and top left side of her bed. Interview on 09/09/21 at 11:17 A.M. with the Director of Nursing (DON) confirmed the resident didn't have full floor mats to the sides of her bed and also confirmed if she were to fall out of her bed, on either side, the floor mat would only protect half of her body rendering it ineffective. She stated she changed the half sized mats to full sized mats. Review of the policy and procedure titled, Managing Falls and Fall Risk, undated, revealed the staff will identify and implement relevant interventions to try to minimize serious consequences of falling. This deficiency substantiates Master Complaint Number OH00125518 and Complaint Number OH00125449 366196 Page 3 of 6 366196 09/09/2021 Altercare Newark South Inc. 17 Forry Street Newark, OH 43055

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and facility policy and procedure, the facility failed to provide physician orders for a continuous positive airway pressure (CPAP) machine and its maintenance. This affected one resident (Resident #27) of two residents reviewed for CPAPs. The census was 27. Residents Affected - Few Findings Include: Review of the closed medical record for Resident #27 revealed an admission date of 07/30/21 and a discharge date of 08/22/21. Diagnoses included encephalopathy, muscle weakness, high blood pressure (HTN), anemia, chronic obstructive pulmonary disease (COPD), diabetes type two, amnesia, and dementia with behavioral disturbances. Review of the Minimum Data Set (MDS) assessment, dated 08/05/21, revealed the resident had a Brief Interview of Mental Status (BIMS) of 11 indicating moderately impaired cognition and the resident required extensive assistance of one staff for bed mobility, transfers, locomotion via wheelchair, dressing, toilet use, and personal hygiene and he required supervision set up only for eating. Review of the plan of care dated 08/02/21 revealed the resident had cardiac impairment related to: HTN, COPD on oxygen and uses CPAP machine, uses a pacemaker, had carotid artery surgery and left upper leg vascular surgery with interventions to administer medications as ordered, administer oxygen as ordered, observe for edema, shortness of breath headache, dizziness, chest pain, nose bleeds, elevated blood pressure, pulse or respirations, obtain lab work per orders, and obtain vital signs per orders. The care plan also revealed the resident had the potential or alteration in respiratory function related to COPD with use of CPAP and oxygen and potential for COVID19 with interventions to administer medications as ordered, administer oxygen and respiratory treatments as ordered, auscultate lung sounds as needed, elevate the head of the bed, encourage fluids, encourage coughing and deep breathing, obtain vital signs as ordered and labs as ordered. Review of the physician orders from July 2021 through August 2021 revealed orders to change oxygen tubing weekly on Mondays, continuous oxygen at 2 liters (L) per nasal cannula every shift and record oxygen saturation, and record oxygen saturation once a month on room air. There was no documented evidence of a physician order for a CPAP machine or its maintenance. Review of the nursing progress notes from July 2021 through August 2021 revealed on 07/30/21 at 10:49 P.M. the resident was resting in bed with his eyes closed and his CPAP was intact and functioning properly; On 08/01/21 at 12:50 A.M. the resident was resting in bed with his CPAP and oxygen on; On 08/01/21 at 8:30 P.M. the resident was lying in bed with oxygen on 2 Liters and CPAP on. The nurse's notes revealed the resident wore his CPAP on the nights of 07/30/21, 07/31/21, 08/01/21, 08/04/21, 08/06/21, 08/08/21, 08/09/21, 08/14/21. On 08/02/21 and 08/20/21 he took his CPAP off and on through the night. Interview on 09/09/21 at 10:59 A.M. with the Director of Nursing (DON) confirmed the resident didn't have physician orders for the CPAP machine or its maintenance, she stated the resident's wife brought the CPAP from home. 366196 Page 4 of 6 366196 09/09/2021 Altercare Newark South Inc. 17 Forry Street Newark, OH 43055

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/09/21 at 11:55 A.M. with Licensed Practical Nurse (LPN) #312 revealed Resident #27's CPAP was placed every night, but he would constantly remove it and staff would attempt to replace it. Review of facility policy titled CPAP/BiPAP Support, undated, revealed staff should review physician orders to determine oxygen concentration and flow, and the PEEP pressure for the machine. They should also follow manufacture instructions for CPAP machine set up and oxygen delivery. This deficiency substantiates Master Complaint Number OH00125518 and Complaint Number OH00125449 366196 Page 5 of 6 366196 09/09/2021 Altercare Newark South Inc. 17 Forry Street Newark, OH 43055

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview, the facility failed to ensure physician orders were transcribed into the Medication Administration Record (MAR) and completed as ordered. This affected one resident (Resident #27) of six residents reviewed for unnecessary medications. The census was 27. Findings Include: Review of the closed medical record for Resident #27 revealed an admission date of 07/30/21 and a discharge date of 08/22/21. Diagnoses included encephalopathy, muscle weakness, high blood pressure, anemia, chronic obstructive pulmonary disease (COPD), diabetes type two, amnesia, and dementia with behavioral disturbances. Review of the Minimum Data Set (MDS) assessment, dated 08/05/21, revealed the resident had a Brief Interview of Mental Status (BIMS) of 11 indicating moderately impaired cognition and the resident required extensive assistance of one staff for bed mobility, transfers, locomotion via wheelchair, dressing, toilet use, and personal hygiene and he required supervision set up only for eating. Review of the plan of care dated 08/02/21 revealed the resident had the potential for changes in blood sugars related to diabetes with interventions to monitor blood glucose as ordered, blood sugar tests, labs and consults as ordered, and give medications and treatments as ordered. Review of the pharmacy recommendations, signed and dated 08/18/21, revealed the pharmacist recommended the resident obtain a Hemoglobin A1C (HgA1C) now and in three months and also recommended the resident have a Glucagon 1 mg subcutaneous or intramuscular injection every 15 minutes as needed for hypoglycemia since he required management for diabetes. The laboratory HgA1C order was not obtained, and the Glucagon injection order was not placed into the MAR. Review of the resident's blood sugars revealed he would not have required a Glucagon injection during his stay at the facility. Interview on 09/08/21 at 2:34 P.M. with the Director of Nursing (DON) confirmed the orders were not completed. This deficiency substantiates Master Complaint Number OH00125518. 366196 Page 6 of 6