Health inspection·February 17, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review the facility failed to ensure functioning call lights were placed within reach of residents. This affected three (Resident's #10, #31 and #38) of three residents reviewed for call light function. The facility census was 42. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, repeated falls, muscle weakness, peripheral vascular disease, and essential hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented to person, place, time, and was a one-staff physical extensive assist for activities of daily living (ADL). Observation on 02/14/22 at 10:19 A.M. revealed Resident #38's call light was not within reach and was located hanging near the floor on the ride side of the bed. Interview on 02/14/22 at 10:19 A.M. with Resident #38 revealed his right side was paralyzed, and he could not reach his call light. Resident #38 revealed his call light did not work. Demonstration on 02/14/22 at 10:20 A.M. of call light function revealed Resident #38's call light was not in working order. Interview on 02/14/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #38's call light was not within reach and was not in working order. Interview and demonstration on 02/14/22 at 10:25 A.M. with Maintenance Director (MD) #342 confirmed Resident #38's call light was not in working order. 2. Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included end stage renal disease, enterocolitis due to clostridium difficile, hyperlipidemia, pneumonia, dependence on renal dialysis, gastro-esophageal reflux disease, morbid obesity, depression, acute respiratory failure with hypoxia, anemia, hypertension, diabetes mellitus, gastrointestinal hemorrhage. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 required extensive assistance of one staff for toileting, bed mobility, dressing, and personal hygiene. Page 1 of 11 366275 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan initiated 12/25/21 revealed Resident #31 was at risk for falls. Interventions included to use call light and wait for assistance, request assistance for all transfers, always keep call light in easy reach and answer promptly. Observation on 02/14/22 at 11:00 A.M. revealed Resident #31 sitting in reclining chair angled to watch television with the call light tied to the grab bar on the bed out of reach. Interview on 02/14/22 at 11:00 A.M. with Resident #31 reported she was unable to reach the call light and would have to yell if she needed assistance. Interview on 02/14/22 at 11:15 A.M. with Medical Records (MR)/State Tested Nursing Assistant (STNA) #306 confirmed the call light was out of reach of Resident #31. MR/STNA #306 had to untangle the call light from the bed's grab bar to hand to Resident #31. 3. Record review for Resident #10 revealed an admission date of 12/09/19 and a readmission date of 08/26/21. Diagnosis included fracture of other parts of pelvis, anxiety disorder, history of falls, and dementia without behavioral disturbance. Record review of the quarterly MDS 3.0 dated 02/01/22 revealed Resident #10 had severely impaired cognition. Resident #10 required extensive assistance of one staff for transfers and limited assistance of one staff for locomotion on the unit. Review of the care plan for dated 08/27/21 revealed Resident #10 was at risk for falls. Interventions included to always keep call light in easy reach and answer promptly and keep the bed in the lowest position while occupied. Observation and interview on 02/14/22 at 10:25 A.M. revealed Resident #10 lying in bed. Resident #10's bed was not at lowest position, and the call light was not within reach. The bed was located against wall with a fall mat on the side of the bed. Resident #10 stated she utilized the call light at times. Observation and interview on 02/14/22 at 10:26 with Administrator #316 verified the observations and stated the call light was wrapped around the grab bar located against the wall. Administrator #316 could not get to the call light to put it within reach of Resident #10. Review of the facility policy titled Answering the Call Light, revised September 2003, revealed the facility had a policy in place to respond to the resident's requests and needs. Review of the policy revealed when a resident was confined to a chair or in bed, the call light was to be within easy reach of the resident. Review of the policy also revealed all defective call lights should be reported to the Nurse Supervisor promptly. Review of the facility document revealed the facility did not implement the policy. This deficiency substantiates Master Complaint Number OH00114368. 366275 Page 2 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure a well-maintained and homelike environment. This affected four residents (Resident's #8, #9, #33 and #37) of 42 residents observed during the annual survey. The facility census was 42 residents. Findings include: Observation on 02/14/22 at 9:45 A.M. with Resident #8 revealed large gouges in the wall behind her bed exposing the wall material beneath the paint. An area of water damage was noted above the heater in Resident #8's room. Interview with Resident #8 at the time of observation revealed she did not know how long these areas had been present. Observation on 02/14/22 at 10:07 A.M. with Resident #9 revealed large gouges in the wall behind her bed. Interview with Resident #9 at the time of observation revealed she had asked staff to do something about it and someone would come in the room to spray for ants, but no one would repair her wall. Observation on 02/14/22 at 11:10 A.M. with Resident #33 revealed a large area behind the bed had been spackled but not repainted and an area above the heater was chipped away and had the inner wall material exposed. Interview with Resident #33 at the time of observation revealed the wall had looked like that since his admission in August 2021. Observation of the facility on 02/14/22 from 4:49 P.M. to 5:26 P.M. with Regional Registered Nurse (RRN) #361 revealed the following concerns: • Resident #8's room had a large gouge to the wall over approximately one foot by one foot behind the bed exposing the inner wall material. Also, above the heater there were areas of wall chipped away exposing the inner wall material. • Resident #9's room had a large gouge approximately one foot by two inches behind the bed. • Resident #33's room had a large area behind the bed approximately two feet by two feet spackled and not painted and an area above the heater was chipped away exposing the inner wall and measured approximately six inches long. • Resident #37's room had an area by her bathroom where the drywall was exposed down to the base of the wall and the floor trim was coming away from the wall. Interview with RRN #361 on 02/14/22 at 4:57 P.M. verified the above areas of concern and revealed 366275 Page 3 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some maintenance issues went into an electronic system where Maintenance Staff (MS) #342 would receive an email of the reported concern. There were no other maintenance support staff at the facility. RRN #361 was requested to bring the surveyor three months of maintenance request documentation. Interview with MS #342 on 02/16/22 at 1:55 P.M. revealed he got hundreds of emails regarding maintenance requests each day. MS #342 confirmed he was the only maintenance staff at the facility and would have to prioritize what tasks would get done each day. MS #342 stated since November 2020 there had been conversations about obtaining plastic sheeting to go behind residents' beds to prevent wall damage from occurring, but he kept getting pulled to other maintenance tasks and it had never come to fruition. MS #342 was requested to bring the surveyor three months of maintenance request documentation. No maintenance request documentation was provided by the end of the annual survey. 366275 Page 4 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

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** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for two (Resident's #30 and #31) of twenty-one residents reviewed for assessments. The facility census was 42. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses including end stage renal disease, enterocolitis due to clostridium difficile, hyperlipidemia, pneumonia, dependence on renal dialysis, gastro-esophageal reflux disease, morbid obesity, depression, acute respiratory failure with hypoxia, anemia, hypertension, diabetes mellitus, gastrointestinal hemorrhage Review of MDS 3.0 assessment dated [DATE] revealed Resident #31 required extensive one staff assistance for toileting. The assessment indicated Resident #31 was always continent of bowel and bladder. Review of bladder and bowel continence documentation for last 30 days revealed Resident #31 was incontinent of bowel and bladder. Review of the care plan initiated 12/25/21 revealed Resident #31 had bowel incontinence. Interventions included to give peritoneal care after each episode of incontinence, apply barrier cream as needed, toilet resident promptly, and toilet resident in advance of need. Interview on 02/16/22 at 10:34 A.M. with State Testing Nursing Assistant (STNA) #352 confirmed incontinence of bowel and bladder for Resident #31. STNA #352 reported Resident #31 needed assistance during toileting. Interview on 02/16/22 at 12:03 P.M. with Registered Nurse (RN) #339 revealed RN #339 was also the MDS coordinator. RN #339 reported they had not completed the assessment for Resident #31. RN #339 reported they had corporate assistance for completing assessments. Interview on 02/16/22 at 12:20 P.M. with Regional Assessment Coordinator (RAC) #362 revealed they had assisted RN #339 with the MDS assessment for Resident #31. RAC #362 indicated review of the look back period for bowel and bladder indicated Resident #31 was incontinent. RAC #362 reported being confused as Resident #31 was continent at the last assessment. RAC #362 reported the STNAs were documenting incorrectly. Interview on 02/16/22 at 2:14 P.M. with Restorative RN #315 revealed Resident #31 had more frequent episodes of incontinence of bowel and bladder since return from hospital on [DATE]. Restorative RN #315 indicated Resident #31 was being reviewed in facility risk meeting for a bowel and bladder restorative program. 2. Record review for Resident #30 revealed an admission date of 10/06/21 with diagnoses including malignant neoplasm of prostate and retention of urine. Record review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had mild cognitive impairment. Review of the bladder and bowel revealed Resident #30 had no indwelling catheter. 366275 Page 5 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 10/07/21 revealed Resident #30 required an alternate means of urinary elimination, and a Foley catheter in place. Review of the physician order dated 10/07/21 at 3:00 P.M. revealed 16 French five milliliter foley catheter to continuous drainage. Resident #30 was to have catheter care every shift. Residents Affected - Few Review of the Treatment Administration Record (TAR) for January 2022 and February 2022 revealed the catheter care was completed as ordered. Observation on 02/16/22 at 7:52 A.M. revealed Resident #30 was lying in bed. Resident #30's Foley catheter was draining clear yellow urine. Interview on 02/16/22 at 3:50 P.M. with MDS RN #339 confirmed Resident #30 had an indwelling Foley catheter since admission on [DATE]. MDS RN #339 confirmed an inaccurate code on the MDS submission dated 01/10/22 regarding indwelling Foley catheter. 366275 Page 6 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

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 observation, interview, and record review the facility failed implement interventions to prevent falls for one resident (Resident #10) of one resident reviewed for falls. The facility census was 42. Findings include: Record review for Resident #10 revealed an admission date of 12/09/19 and a readmission date of 08/26/21 with diagnoses including fracture of other parts of pelvis, anxiety disorder, history of falls, and dementia without behavioral disturbance. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had severely impaired cognition. Resident #10 required extensive assistance of one staff for transfer and limited assistance of one staff for locomotion on the unit. Record review of the care plan dated 08/27/21 revealed Resident #10 was at risk for falls. Interventions included always keep the call light within easy reach and answer promptly and keep the bed in the lowest position while occupied. Observation and interview on 02/14/22 at 10:25 A.M. revealed Resident #10 lying in bed. Resident #10's bed was not in the lowest position, and the call light was not within reach. The bed was located against the wall, and a fall mat was on the side of the bed. Resident #10 stated she utilized the call light at times. Observation and Interview on 02/14/22 at 10:26 A.M. with Administrator #316 verified the observations and stated the call light was wrapped around the grab bar located against the wall, and the bed was not in the lowest position. Administrator #316 could not get to the call light to put it within reach of Resident #10. This deficiency substantiates Master Compliant Number OH00114368 and Complaint Number OH00111616. 366275 Page 7 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, taste test, and Diet and Nutrition Manual review the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected five residents (Resident's #5, #10, #23, #24 and #40) who were prescribed a pureed diet of 42 residents who consumed meals from the facility's kitchen. The facility census was 42. Findings include: 1. Observation on 02/15/22 at 12:15 P.M. of the lunch meal revealed that the pureed stuffed peppers and pureed peas and carrots had lumps, skins, and did not appear smooth. The pureed stuffed peppers and peas and carrots were tasted. The mixture was not smooth and not of proper consistency. Interview with Dietary Manager (DM) #363 verified the consistency of the pureed stuffed peppers and pureed peas and carrots. 2. Observation on 02/15/22 at 3:00 P.M. of the puree preparation revealed [NAME] #338 was preparing pureed chicken tenders for dinner meal. Taste test of puree chicken tenders revealed chunks of breading. The mixture was not smooth and not of proper consistency. Interview with DM #363 verified the consistency of the pureed chicken tenders. Interview with DM #363 on 02/15/22 at 3:10 P.M. indicated upon taste test regarding the food processor I think we need a new blade. Review of the resident diet list revealed Resident's #5, #10, #23, #24 and #40 were prescribed a pureed diet. Review of the Diet and Nutrition Care Manual, dated 2019, revealed pureed foods are generally cohesive, moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product. 366275 Page 8 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident record contained current and accurate information. This affected three (Resident's #13, #37 and #348) of three residents reviewed for accurate medical records. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, and gastroesophageal reflux disease without esophagitis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was alert with cognitive impairment and required assistance of one staff for activities of daily living (ADL). Review of the physician orders dated 12/27/21 revealed an order stating if bleeding occurs from the dialysis site, apply pressure, call 911, and document. Review of the physician orders dated 12/29/21 revealed an order to assess the dialysis site before and after dialysis for unusual findings, document unusual findings, and report to physician. Review of the physician orders dated 01/06/22 revealed an order to give one Renvela 0.8 packet three times a day related to end stage renal disease mixed with four ounces of water with meals three times a day. Review of the physician orders dated 01/10/22 revealed an order for a renal diet consisting of mechanical soft-textured chopped meats with thin consistency liquids. Review of all other documented physician orders located in the electronic and manual medical record revealed no other orders related to dialysis. Review of the care plan dated 12/27/21 revealed Resident #13 required dialysis with interventions that included dialysis as ordered and monitor daily for signs and symptoms of infection. Interview on 02/16/22 at 12:01 P.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #13 did not have a dialysis order in place. 2. Review of Resident #37's medical record revealed an admission date of 10/07/21 with diagnoses including end stage renal disease, chronic kidney disease, anemia, pneumonia and type two diabetes. Review of Resident #37's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had moderately cognitive impairment, had no behaviors, required supervision for eating and required extensive assistance of one staff for dressing. The assessment indicated Resident #37 received dialysis. Review of Resident #37's current physician orders included an order dated 10/08/21 stating assess the dialysis site before and after dialysis for unusual findings, document yes or no for presence/absence of unusual findings. No physician order for dialysis services was available in the paper chart or the electronic medical record. 366275 Page 9 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0842 Level of Harm - Minimal harm or potential for actual harm Interview on 02/16/22 at 11:18 A.M. with LPN #313 revealed Resident #37 was currently out of the facility at dialysis. LPN #313 reviewed Resident #37's electronic medical record and paper chart and verified no physician order for dialysis was in place. LPN #313 explained the nurse who was on the hall receiving a new resident was responsible for their admission orders and would have obtained an order for Resident #37's dialysis treatments. LPN #313 denied any concerns regarding Resident #37 and dialysis. Residents Affected - Some The Administrator was made aware of the above findings during an interview on 02/16/22 at 4:18 P.M. 3. Review of the medical record revealed Resident #348 was admitted on [DATE] with diagnoses including left ankle/foot osteomyelitis, personal history of COVID-19, hypertension, dependence on renal dialysis, end stage renal disease, chronic anemia, atrial flutter, hyperlipidemia, type II diabetes mellitus, diabetic retinopathy, peripheral vascular disease, and orthopedic aftercare following surgical amputation. Review of the MDS 3.0 assessment revealed an admission assessment was in progress. Review of the baseline care plan dated 02/10/22 revealed Resident #348 required dialysis. Interventions included to provide dialysis as ordered, monitor daily for signs and symptoms of infection, and no blood pressure or blood draws in dialysis access arm. Review of the current physician's orders for 02/16/22 for Resident #348 revealed no order to specify details of dialysis treatments. There was no order to indicate treatment days, time, or location of dialysis. Interview on 02/16/22 at 2:32 P.M. with Registered Nurse (RN) #339 verified the lack of dialysis order. 366275 Page 10 of 11 366275 02/17/2022 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review the facility failed to ensure it had functional call lights in place. This affected one (Resident #38) of one resident reviewed for call light functioning. The facility census was 42. Residents Affected - Few Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, repeated falls, muscle weakness, peripheral vascular disease, and essential hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented to person, place, time, and required one-staff physical extensive assist for activities of daily living (ADL). Observation on 02/14/22 at 10:19 A.M. revealed Resident #38's call light was not within reach and was located hanging near the floor on the ride side of the bed. Interview on 02/14/22 at 10:19 A.M. with Resident #38 revealed his right side was paralyzed and he could not reach his call light. Resident #38 revealed his call light did not work. Demonstration on 02/14/22 at 10:20 A.M. of call light function revealed Resident #38's call light was not in working order. Interview on 02/14/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #38's call light was not within reach and was not in working order. Interview and demonstration on 02/14/22 at 10:25 A.M. with Maintenance Director (MD) #342 confirmed Resident #38's call light was not in working order. Review of the facility document titled Answering the Call Light, revised September 2003, revealed the facility had a policy in place to respond to the resident's requests and needs. Review of the policy revealed when a resident was confined to a chair or in bed, the call light was to be within easy reach of the resident. Review of the policy also revealed all defective call lights should be reported to the Nurse Supervisor promptly. Review of the facility document revealed the facility did not implement the policy. This deficiency substantiates Master Complaint Number OH00114368. 366275 Page 11 of 11