Health inspection·February 23, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure notification of a weight change was provided to Resident #5's physician and notification of falls was provided to the family of Resident #71. This affected two residents (Resident #5 and Resident #71) of two residents reviewed for notification. Findings include: 1. Resident #5 was admitted on [DATE] with diagnoses included congestive heart failure (CHF), acute pulmonary edema, acute respiratory failure with hypoxia, (low levels of oxygen), chronic obstructive pulmonary disease (COPD) and atrial fibrillation (irregular, often rapid heart beat). Resident #5 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the hospital After Visit Summary (AVS) of 12/30/22 revealed Resident #5 was treated for acute on chronic respiratory failure with hypoxia. Instructions included weighing the resident every day in the morning after they void and notifying the doctor of a weight gain of three pounds or more in one day or a total of five pounds or more in one week. Review of physician order dated 12/30/22 revealed daily weights were ordered with instructions to contact the physician for weight gain of three pounds (lbs) in 24 hours or five lbs in one week. Review of the Medicare 5-day Minimum Data Summary (MDS) 3.0 of 01/05/23 revealed the resident was cognitively intact, required extensive assist of one for activities of daily living (ADL), had shortness of breath when exerting or lying flat, and received diuretic therapy and oxygen therapies. Review of the weights for Resident #5 revealed a five pound weight gain from 01/12/23 to 01/14/23, an additional three pound weight gain from 01/14/23 to 01/15/23 and an additional three pound weight gain between 01/15/23 and 01/23/23. There was no documentation of the physician being notified of the weight gains. Resident #5 medical record revealed the resident hospitalized on [DATE] and returned to the facility on [DATE]. Review of the AVS of 01/31/23 revealed the resident was treated for CHF with unknown left ventricular ejection fraction (LVEF), a measure of how well the heart is pumping blood. Interview on 02/21/23 at 03:07 P.M. with the Director of Nursing (DON) verified Resident #71's Page 1 of 24 366281 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0580 physician should have but was not notified of Resident #5's weight gain as ordered. Level of Harm - Minimal harm or potential for actual harm Review of the May 2020 facility policy Change in Condition revealed the facility contacted a resident's physician when there was a significant change in condition, a need to alter treatment significantly or a decision made to transfer a resident. Residents Affected - Few 2. Review of medical record revealed Resident #71 was admitted on [DATE] and diagnoses included Alzheimer's disease, dementia, intermittent explosive disorder, insomnia, history of falling, and abnormalities of gait and mobility. Review of 01/05/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #71 was severely cognitively impaired and required extensive assistance of two persons for bed mobility, transfers, dressing and toileting; total dependence of one person for bathing; and total dependence of two persons for bathing. Review of care plan initiated 08/02/22 revealed Resident #71 was at risk for falls related to abnormalities of gait and mobility, lack of coordination, dementia with behavioral disturbances, and insomnia with interventions that included observe out of bed activities as needed, keep pathways and walkways clear, and encourage proper use of assistive devices as needed. Review of a facility incident report dated 01/12/23 revealed Resident #71 had an unwitnessed fall on 01/12/23 at 2:50 A.M. The physician was notified on 01/13/23 at 8:00 A.M. and the daughter was notified on 01/12/23 at 12:30 P.M. Review of facility fall incident report dated 02/15/23 revealed Resident #71 had an unwitnessed fall in room on 02/15/23 at 2:45 A.M. with the resident representative being notified on 02/15/23 at 12:36 P.M. Interview on 02/16/23 at 9:30 A.M. with Resident #71's representative revealed she was unaware of Resident #71's fall on 02/15/23 until during a visit on 02/15/23 when a nurse notified the representative around 1:30 P.M. of the need to obtain the resident's vitals due to the recent fall. Interview on 02/21/23 at 10:30 A.M. with the Director of Nursing revealed if a fall happened in the middle of the night, she would expect the resident representatives and the physicians to be notified first thing in the morning. She confirmed that notifying Resident #71's representative in the afternoon on 01/12/23 and 02/15/23 of Resident #71's falls on 1/12/23 at 2:50 A.M. and 02/15/23 at 2:45 A.M. and the physician being notified on 01/13/23 at 8:00 A.M. of Resident #71's fall on 01/12/23 at 2:50 A.M. was too late. Review of facility policy titled Notification Of Changes, revised November 2016, revealed notifications would be made as soon as possible and would be documented in the medical record. 366281 Page 2 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Residents #65 and #134's comprehensive care plans included goals and interventions to address all behaviors. This affected two residents (Resident #65 and Resident #134) of four residents reviewed for behaviors. The census was 82. Findings include: 1. Resident #65 was admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified dementia, muscle wasting and atrophy, general anxiety and major depressive disorder. Review of physician orders included an order for the resident to ambulate with supervision and no assistive device, and a Wanderguard to the right ankle. Review of the quarterly Minimum Data Summary (MDS) 3.0 dated 01/01/23 revealed Resident #65 was severely cognitively impaired, exhibited wandering behavior and ambulated independently. Review of the care plan of 01/01/23 revealed care areas included risk for elopement as evidenced by exit-seeking, intruding on the privacy or activities of others, physical aggression with care and medication refusal. There was no mention of possible harmful behaviors such as ingesting non-food items. Review of progress notes of 10/12/22 and 12/21/22 revealed Resident #65 was found by staff drinking peri-wash. It was unknown which room she had gotten the peri-wash from or how much she had ingested on both dates. Multiple observations from 02/13/23 06:38 P.M. to 02/16/23 at 8:35 A.M. revealed Resident #65 wandered throughout the secured unit, in and out of several other resident rooms unsupervised. Interview on 02/15/23 at 05:23 P.M. with Licensed Practical Nurse (LPN) #501 verified Resident #65 was at times a problem due to her wandering and intrusion into other residents' rooms. She had taken numerous items from these rooms including clothing, eyeglasses and TV remote controls. The LPN revealed a box of remotes for all the residents' TVs which were kept at the nurse station and residents needed to request their remote when needed. She also revealed a number of pairs of eyeglasses in a drawer at the nurse station which Resident #65 had collected and it was not known to whom they belonged. Observations on 02/16/22 from 10:28 A.M. to 10:38 A.M. on the secured unit revealed 16 bottles of Perifresh (perineal cleanser with aloe vera) unsecured in bathrooms or on top of resident dressers in 12 of the 16 rooms checked in the secured unit. The bottles contained a warning to keep out of the reach of children. Interview on 02/16/23 at 10:40 A. M. with LPN #313, who discovered Resident #65 drinking Perifresh on 10/12/22 verified the Perifresh was not secured in residents rooms and should have been locking in the top drawer of each resident's nightstand. Interview on 02/16/23 12:07 P.M. with Quality Assurance (QA) Nurse #603 verified the Perifresh 366281 Page 3 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should not have been out in resident rooms. The facility did a QA project after the first incident of ingestion on 10/12/22. She was unable to explain how the second incident of ingestion occurred. She also revealed Resident #65 was for the most part, non-verbal but could answer yes or no questions. She verified the care plan did not include the history of ingesting peri-wash. The facility was unable to provide a specific behavior management policy, but did provide a copy of the undated Alzheimer Association (AA) Suggestions for Responding to Dementia Related Behaviors and the March 2022 AA Dementia Training for Direct Care Workers. 2. Review of the medical record for Resident #134 revealed the resident was admitted to the secured unit on 01/25/23 with diagnoses including Alzheimer's disease with late onset, dementia, unspecified severity, with other behavioral disturbance, cognitive communication deficit, and prostatic hyperplasia. Review of the Medicare 5-day MDS 3.0 of 01/31/23 revealed Resident #134 was severely cognitively impaired, exhibited physical behaviors towards others, rejection of care and wandering, required extensive assist of one for activities of daily living (ADLS), required supervision/limited assist for walking, and was frequently incontinent of bladder. The resident was not on a toileting program. Resident #134's care plan of 01/26/23 included care areas for cognition, difficulty with communication related to Alzheimer's disease and dementia, rarely understands and was rarely understood, incontinence and behaviors of rejection of care and wandering. There was no mention of urination in inappropriate places. Review of 1/31/2023 progress notes revealed the nurse was alerted by a family member that Resident #134 was in another resident's room. Upon entering room Resident #134 was found with his hands in his pants sitting on another resident's bed. The nurse was able to escort the resident out of the room. The physician ordered Zyprexa (an anti-psychotic). Review of progress notes of 02/06/23 revealed Resident #134 walked into another room, pulled his pants down and urinated on the floor. He refused to let staff put on clean dry pants or do peri-care. Review of the progress note of 02/14/23 revealed Resident #134 wandered went into another resident's room and urinated on the floor. The incident was reported by a family member of a third resident. Observation on 02/15/23 at 7:54 A.M. revealed Resident #134 walked out of his room and urinated all over the floor in the hallway. He was redirected back into his room by staff. Interview on 02/15/23 at 5:23 P.M. with Licensed Practical Nurse (LPN) #314 revealed the LPN was not aware of the incident with Resident #134 earlier in the day. Staff usually reported behaviors to the nurses and they were logged on the behavior tracking for each resident. She verified Resident #134 had urinated in inappropriate places previously and staff should be monitoring him for toileting. Interview on 02/16/23 at 8:41 A.M. with State Tested Nursing Assistant (STNA) #413 verified she witnessed Resident #134 urinating on the floor the previous day but did not document the behavior or tell the nurse. She revealed she had not received any training on dealing with behaviors. Interview on 02/21/23 at 11:47 A.M. with Restorative Nurse (RN) #605 verified Resident #134 had instances of urinating in inappropriate places, was not on a toileting program, but may benefit from a 366281 Page 4 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0656 toileting program. Level of Harm - Minimal harm or potential for actual harm The facility was unable to provide a specific behavior management policy, but did provide a copy of the undated Alzheimer Association (AA) Suggestions for Responding to Dementia Related Behaviors and the March 2022 AA Dementia Training for Direct Care Workers. Residents Affected - Few 366281 Page 5 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 and interview the facility failed to provide comprehensive assessment (including weight monitoring), monitoring and physician notification for Resident #5 related to a diagnosis of congestive heart failure to prevent hospitalization. In addition, the facility failed to ensure non-pressure related wound care was provided timely for Resident #44. This affected one resident (Resident #5) of two residents reviewed for hospitalization, and one resident (Resident #44) of three residents reviewed for wound care. The census was 82. Residents Affected - Few Findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses included CHF, acute pulmonary edema, acute respiratory failure with hypoxia, (low levels of oxygen), chronic obstructive pulmonary disease (COPD) and atrial fibrillation (irregular, often rapid heart beat). Record review revealed Resident #5 was hospitalized from [DATE] to 12/30/22. Review of the hospital After Visit Summary (AVS) from 12/30/22 revealed Resident #5 was treated for acute on chronic respiratory failure with hypoxia. Instructions included weighing the resident every day in the morning after the resident voided and notifying the doctor of a weight gain of three pounds (lbs) or more in one day or a total of five pounds or more in one week. Review of Resident #5's physician orders revealed an order, dated 12/30/22 for daily weights with instructions to contact the physician for weight gain of three lbs in 24 hours or five lbs in one week. Review of the Medicare 5-day Minimum Data Summary (MDS) 3.0, dated 01/05/23 revealed the resident was cognitively intact, required extensive assist of one for activities of daily living (ADL), had shortness of breath when exerting or lying flat, and received diuretic therapy and oxygen therapies. Review of the weights for Resident #5 revealed a five pound weight gain was noted from 01/12/23 to 01/14/23, an additional three pound weight gain was noted from 01/14/23 to 01/15/23, and an additional three pound weight gain was noted between 01/15/23 and 01/23/23. There was no evidence of the physician being notified of the weight gains during this time period. In addition, there were no weights recorded as ordered on 01/08/23, 01/17/23, 01/18/23, 01/19/23, 01/20/23, 01/20/23 or 01/22/23. Review of Resident #5's progress notes dated 01/17/23 revealed he was seen at the CHF clinic and received Bumex (diuretic medication) 2 milligrams via intravenously. Resident #5 was scheduled for follow up on 01/24/23. Review of the 01/24/23 CHF clinic note revealed Resident #5 arrived at the CHF clinic visibly short of breath with accessory muscle breathing. The resident also presented with pitting edema from the feet up to mid back. The resident was transferred to the emergency department (ED). Review of the ED note of 01/24/23 revealed Resident #5 was short of breath with rales (abnormal crackling or rattling chest sounds), abdominal distension and edema of bilateral legs. The resident reported his CHF had been getting worse since June. The resident was admitted for treatment of CHF and returned to the facility on [DATE]. 366281 Page 6 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the AVS, dated 01/31/23 revealed the resident was treated for CHF with unknown left ventricular ejection fraction (LVEF), a measure of how well the heart was pumping blood. Review of a care plan, dated 02/06/23 revealed care areas included CHF with interventions including monitor breath sounds, any signs or symptoms of CHF, oxygen and diuretic therapies and alteration in respiratory status. Interview on 02/21/23 at 03:07 P.M. with the Director of Nursing (DON) verified daily weights, were not obtained as ordered for Resident #5 per physician and hospital discharge order. The monitoring of daily weights allows an assessment/indicator related to congestive heart failure, including timely identification of acute changes in condition. 2. Review of Resident #44's medical record revealed an admission date of 08/17/22 and diagnoses included multiple fractures ribs left side, dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Resident #44's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #44 had severe cognitive impairment. Resident #44 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #44 did not have skin tears. Review of Resident #44's five day Medicare MDS assessment dated [DATE], revealed Resident #44 had no skin tears. Review of Resident #44's Weekly Skin Evaluation dated 02/01/23, revealed Resident #44 had bilateral upper extremity multiple skin tears, some healing. Resident #44 had a left elbow skin tear from a fall and discoloration, had a left hand by the thumb skin tear from a fall, had bilateral lower extremities discoloration all over with healed skin tears, and left outer thigh bruising. Review of Resident #44's physician orders dated 02/01/23 through 02/14/23, did not reveal treatment orders for Resident #44's skin tears to bilateral arms. Observation on 02/14/23 at 11:10 A.M. of Resident #44 revealed he was wearing a short sleeve shirt and multiple areas of dark purple bruising and multiple dressings were noted on both his arms. Further observation of Resident #44 revealed he had areas of redness and bruising, and multiple dressings on his bilateral legs. Observation revealed none of the multiple dressings on Resident #44's arms and legs were dated. Interview on 02/14/23 at 11:15 A.M. with Licensed Practical Nurse (LPN) #310 confirmed Resident #44 had multiple areas of bruising and multiple adhesive dressings on his arms and legs which were undated. LPN #310 checked Resident #44's orders and indicated Resident #44 did not have treatment orders for the wounds observed on his arms and legs. LPN #310 stated Resident #44 picked off the dressings and she would replace them if she noticed they were missing. LPN #310 stated the wounds on Resident #44's arms and legs were skin tears, and Resident #44 had a fall and that was why he had bruises on his arms and legs. Interview on 02/14/23 at 1:22 P.M. with the DON revealed Wound Nurse #701 was let go on Friday due to performance. The DON stated the facility was doing skin sweeps, checking physician orders and knew there were issues with wounds. Observation on 02/15/23 at 8:20 A.M. of Resident #44 with Wound Nurse Practitioner (WNP) #651 and 366281 Page 7 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Registered Nurse/MDS Nurse/Wound Nurse (RN/MDS/WN) #605 after surveyor intervention revealed Resident #44 had bilateral arm bruising, some small scabbed areas, and multiple undated dressings on both arms. WNP #651 removed the dressings on Resident #44's arms and a long curved six inch wound held together by steri-strips was noted on his right upper arm. WNP #651 did not remove the steri-strips from the wound. There was a small to moderate amount red drainage noted on Resident #44's right upper arm. Resident #44's right arm was noted to have a small skin tear with a small amount clear drainage, and the elbow had an open area about the size of a dime. Resident #44's right arm wounds were cleansed with normal saline solution and Xeroform and Kerlix were applied. Observation of Resident #44's left arm revealed a small skin tear with clear drainage, and his elbow had a red open area about the size of a nickel. Resident #44's elbow area had a small to moderate amount of pink colored drainage, and Resident #44 cried out when WNP #651 cleansed the area with normal saline solution. WNP #651 provided instructions to cleanse the wounds with normal saline solution and apply Xeroform and Kerlix on Monday, Wednesday and Friday. Further observation of Resident #44's legs revealed he had two skin tears on his right shin, and another skin tear on his left leg. WNP #651 cleansed the skin tears with normal saline solution, and applied Xeroform and Kerlix. Review of Resident #44's Wound Care progress notes dated, 02/15/23, included WNP #651 was asked to evaluate multiple skin tears to Resident #44's extremities. Resident #44 had fragile skin and nursing reported even bumping the bed rail could cause skin tears. The progress notes revealed Resident #44 had a skin tear to his right upper arm and measurements were length 2.5 centimeter (cm), width 6.0 cm, and depth was 0.1 cm. Steri-strips to the area were intact with well approximated skin flap. Apply Xeroform to protect, wrap with Kerlix to protect fragile skin, and please no adhesives to the skin. Treatments were ordered for Monday, Wednesday, Friday and as needed. Resident #44 had a skin tear to the left shin and measurements were length 1.3 cm, width 1.4 cm, and depth was 0.1 cm. Resident #44 had a skin tear to the right elbow and the length was 1.1 cm, width 1.0 cm, and depth was 0.1 cm. Resident #44 had a skin tear to the right upper arm posterior and measurements were length 1.9 cm, width 0.5 cm, and depth was 0.1 cm. Resident #44 had a skin tear to the left elbow and measurements were length 1.6 cm, width 1.0 cm and depth 0.1 cm. Resident #44 had a skin tear to the right shin and length was 2.2 cm, width 2.0 cm and depth 0.1 cm. Instructions were to cleanse skin tears with normal saline solution, apply Xeroform and wrap with Kerlix on Monday, Wednesday, Friday and as needed, and to please use no adhesives. Review of facility policy titled, Pressure Ulcer Prevention and Care Protocol, revised 06/2022, included the plan of care protocol for protection against pressure, friction and shear included assist with transfers, ambulation, and mobility as needed. Protect skin from mechanical injury through the use of lift sheets, trapeze, etcetera. Keep linens smooth and unwrinkled. Consult with physical and occupational therapy or restorative nursing to assist with mobility and positioning as needed. 366281 Page 8 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, interview, record review and review of the facility policy, the facility failed to implement a comprehensive and individualized pressure ulcer prevention program, including turning and repositioning to prevent the development of in-house pressure ulcers for Resident #19. The facility also failed to timely identify and treat pressure ulcers for the resident. Residents Affected - Few Actual Harm occurred on 01/20/23 when Resident #19, who was cognitively impaired and required extensive assistance from two staff for bed mobility and transfers, identified to have developed two in-house acquired unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure ulcers to the left buttock. Prior to the identification of the new pressure ulcers, on 01/02/23 and 01/09/23 the areas had been noted to be red, with no evidence of treatment or new interventions being in place. In addition, there was no evidence turning and repositioning was being provided as planned prior to the development of the pressure ulcers. This affected one resident (#19) of three residents reviewed for pressure ulcers. The facility census was 82. Findings include: Review of Resident #19's medical record revealed an admission date of 11/15/18 with diagnoses including end stage renal disease, dependence on renal dialysis and type two diabetes mellitus with foot ulcer. Review of Resident #19's physician orders, dated 09/08/22 revealed an order to turn and reposition every two hours when in bed. Review of Resident #19's physician's orders, dated 09/14/22 revealed an order for Chamosyn to buttocks twice a day for prevention and protection (the order was for the treatment to be provided every day shift for skin protection). Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/01/23, revealed Resident #19 had moderate cognitive impairment. Resident #19 required extensive assistance of two staff members for bed mobility and toilet use. Resident #19 required total dependence from two staff members for transfers and was always incontinent of urine and bowel. The assessment revealed Resident #19 did not have any pressure ulcer or injury. Review of Resident #19's care plan, dated 01/01/23, revealed Resident #19 had potential, actual impairment to skin integrity related to immobility and incontinence secondary to ESRD (end stage renal disease) dialysis dependent, spinal stenosis, diabetes with polyneuropathy, anxiety, depression and other diagnoses. The goal developed was for Resident #19 to maintain or develop clean and intact skin by the review date. Interventions included to follow facility protocols for treatment of injury, see Medication and Treatment Administration Records (MAR and TAR); monitor, document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etcetera to the physician; weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #19's Braden Scale For Predicting Pressure Sore Risk dated, 01/01/23 revealed Resident #19 was at risk for developing a pressure ulcer, injury. 366281 Page 9 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0686 Review of Resident #19's progress notes dated 12/26/22 through 01/20/23, did not reveal documentation Resident #19 had a reddened area to her sacral area or left buttocks. Level of Harm - Actual harm Residents Affected - Few Review of Resident #19's TAR and State Tested Nursing Assistant (STNA) documentation from 01/01/23 through 02/21/23 revealed although the TAR was signed off for staff turning and repositioning, the STNA documentation lacked documentation Resident #19 was turned and repositioned every two hours, every shift while in bed. Review of Resident #19's shower sheet, dated 01/02/23 revealed redness was noted on Resident #19's butt. The sheets dated 01/04/23 and 01/09/23 revealed redness on Resident #19's butt and cream was applied. The shower sheet, dated 01/12/23 revealed a scabbed area, redness, and cream applied identified on the buttock area. The shower sheet, dated 01/20/23 revealed a left butt unstageable area. The shower sheet, dated 01/23/23 revealed redness, a scabbed area, (last week was unstageable) and Clinical Director #601. Resident #19's shower sheets were signed they were received by nurses. Review of Resident #19's medical record revealed no evidence of follow up to the skin redness identified on 01/02/23 or the continued skin redness and scabbed area identified on 01/12/23. Review of Resident #19's progress note, dated 1/20/2023 at 4:28 P.M. revealed Resident #19 had two unstageable wounds on her left buttock. Zinc and Allevyn were applied. Further review did not reveal measurements or a description of the wounds were completed at this time. Review of Resident #19's Weekly Skin Evaluation, dated 01/20/23, revealed Resident #19 had a left buttock unstageable wound, and zinc and Allevyn were applied. Further review did not reveal measurements or a description of the wound was completed. Review of Resident #19's physician orders, dated 01/20/23 through 01/24/23 did not reveal orders for treatment of an unstageable wound to the left buttock. Review of Resident #19's physician's orders revealed an order, dated 01/24/23 (four days later) for Benzoin compound external tincture (benzoin compound), apply to left butt purple area topically every night shift, every three days for wound care. Clean with normal saline solution, tincture of benzoin to area, foam change every three days. This order was discontinued 01/25/23. Review of Resident #19's physician's orders, revealed an order dated 01/25/23, for Allevyn thin pad four by four (gauze pads and dressings), apply to left buttocks topically every day shift every three days for wound care. The order was discontinued 02/08/23. Review of Resident #19's medical record including Weekly Skin Evaluations and progress notes from 01/20/23 through 01/23/23 did not reveal documentation of Resident #19's left buttock unstageable wound. Further review of Resident #19's progress notes did not reveal the physician was notified of the unstageable wound to her left buttock. A Skin and Wound Evaluation, dated 01/24/23, revealed Resident #19 had a deep tissue injury (purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the left buttock. The evaluation form indicated the deep tissue injury was in-house acquired, and was identified on 01/20/23. The wound measurements were length 4.0 centimeters (cm), width 1.8 cm and depth was unable to be determined. Percent of epithelial tissue was 100 percent of the wound was covered, surface intact. 366281 Page 10 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of Resident #19's progress note, dated 01/25/23 at 4:23 P.M., revealed left butt with pressure consistent with deep tissue injury. The wound was dark purple and had intact edges. A foam dressing was applied per orders. Review of Resident #19's Treatment Administration Record (TAR) dated 01/26/23 through 02/07/23, revealed orders for Allevyn thin pad four by four (gauze pads and dressings), apply to left buttocks topically every day shift every three days for wound care. Review of the TAR revealed a treatment was initiated 01/26/23, but was not documented it was completed on 01/29/23 or 02/07/23 as ordered by the physician. Review of Resident #19's Skin and Wound Evaluation, dated 02/07/23 revealed a deep tissue injury to the left buttock, in-house acquired on 01/20/23 with measurements of length 0 cm, and width 0 cm, depth not applicable. The evaluation noted the area was resolved. Review of Resident #19's progress note, dated 02/16/23 at 3:20 P.M., revealed during an observation of Resident #19's skin, she was observed to have an area to the left upper buttocks. The area was cleansed with normal saline solution, Medi-honey and Allevyn dressing were applied. Entire area measured 4.1 cm (length) by 2.6 (width) cm, red non blanchable tissue with an open area to the lower portion of the wound measuring 0.2 cm (length) by 0.3 cm (width) by 0.1 cm (depth), remainder of bilateral buttocks intact. Resident #19's husband and physician updated. Interview on 02/14/23 at 1:22 P.M. with Director of Nursing (DON) revealed Wound Nurse #701 was let go on Friday due to performance. The DON stated the facility was doing skin sweeps, checking physician orders and knew there were issues with wounds. Observation on 02/16/23 at 8:25 A.M. revealed Resident #19 was sitting in a wheelchair in the common area waiting for breakfast to be served. Resident #19's head was tilted to the right side and her eyes were closed. Interview on 02/16/23 at 9:20 A.M. with Registered Nurse (RN) #307 revealed Resident #19 was not always alert in the morning. Interview on 02/16/23 at 12:30 P.M. with Registered Nurse/MDS Nurse/Wound Nurse (RN/MDS/WN) #605 revealed Resident #19's pressure ulcer to her left buttock was healed. Observation on 02/16/23 at 2:56 P.M. of Resident #19 with RN/MDS/WN #605 revealed after surveyor intervention RN/MDS/WN #605 entered Resident #19's room and observed Resident #19's buttocks and sacral area. Observation of Resident #19's left sacral area and buttocks revealed a dark red area with a few small areas of purple mixed with the dark red. There was a small open area noted on the lower portion of the wound. RN/MDS/WN #605 confirmed observation of Resident #19's sacral area and buttocks revealed a dark red and purple area, and a small open area on the lower portion of the wound. The dark red and purple area was approximately two inches by one inch in size. The skin did not blanche in the center of the wound and slowly blanched around the perimeter of the wound. Review of Resident #19's physician orders dated, 02/16/23, revealed an order to cleanse open area to left upper buttocks with normal saline solution, apply Medihoney (wound healing) and Allevyn dressing, change Monday, Wednesday, Friday, every day shift. Observation on 02/21/23 at 8:41 A.M., 10:01 A.M., 10:12 A.M., 11:28 A.M., and 12:16 P.M. revealed 366281 Page 11 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0686 Level of Harm - Actual harm Residents Affected - Few Resident #19 lying on her back in bed, with the head of the bed elevated and her eyes closed. There was no observation of staff members turning and repositioning Resident #19 or encouraging Resident #19 to be turned and repositioned. Interview on 02/21/23 at 12:16 P.M. with State Tested Nursing Assistant (STNA) #700 revealed Resident #19 was lying in bed and did not want to get out of bed. STNA #700 confirmed Resident #19 had been lying in the same position all day and was not turned and repositioned. Interview on 02/21/23 at 12:18 P.M. with Resident #19 revealed she did not want to get out of bed and was feeling lazy today. Resident #19 stated no staff members including STNA #700 repositioned her or encouraged her to reposition herself while she was lying in bed. Interview on 02/22/23 at 9:49 A.M. with State Tested Nursing Assistant (STNA) #441 revealed Resident #19 had a red spot on her butt about a month ago. STNA #441 stated she told RN #307 about the red spot and put cream on it. STNA #441 stated the red spot opened up a couple days later. Review of facility policy titled Pressure Ulcer Prevention and Care Protocol, revised 06/2022, included the plan of care protocol for protection against pressure, friction and shear included reduce pressure over bony prominences, turn and repositioning of the resident. Residents would be turned and repositioned at least every two hours or as outlined in the plan of care based on resident's individual needs, identified through assessment. 366281 Page 12 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interviews and record review, the facility to ensure Resident #1's cervical collar was in place as ordered to help prevent further contracture, comfort while in a chair, and position for proper swallowing. This affected one (Resident #1) of one resident reviewed for position and mobility. The facility census was 82. Findings include: Review of medical record for Resident #1 revealed an admission date of 03/09/05 and diagnoses included unspecified injury of head, hemiplegia (paralysis) affecting right dominant side, unspecified joint contracture (a condition that limits or prevents movement), and oropharyngeal phase dysphagia (difficulty swallowing). Review of 01/04/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was severely cognitively impaired and required extensive assistance of two persons for bed mobility, dressing, and toileting; extensive assistance of one person for eating, personal hygiene; and total dependence of two persons for transfers and bathing. Review of care plan, initiated 07/02/19, revealed Resident #1 had a potential for alteration in comfort related to contractures of right upper extremity, had a swallowing problem related to dysphagia diagnosis, and would receive person-centered plan of care with interventions which included wearing a cervical collar brace when out of bed and in the tilt in space wheelchair and eating in an upright position. Review of orthotic progress note dated 3/16/22 revealed Resident #1, who had a torticollis contracture (a condition in which the neck was involuntarily in a twisted position), had a custom splint made to help prevent further contracture, comfort while in chair, and position for proper swallowing. Review of physician orders for Resident #1 revealed an order dated 04/15/22 for a cervical collar brace to be worn when out of bed in tilt in space wheelchair. Review of Resident #1's Treatment Administration Record revealed Resident #1 was not wearing the brace on 02/11/23 since it was being washed and on 02/12/23 and 2/13/23 it was unable to be located. Observations on 02/14/23 at 11:04 A.M. and on 02/15/23 at 7:54 A.M. and 12:25 P.M. revealed Resident #1 was sitting in wheelchair with head tilted to the right with the ear touching the shoulder. No cervical collar was observed on Resident #1. Interview on 02/16/23 at 1:35 P.M. with Registered Nurse (RN) #307 revealed Resident #1's cervical collar was to be worn when out of bed and in tilt in space wheelchair and the cervical collar helped with positioning of the neck. RN #307 confirmed the Resident #1's cervical collar had been missing since 02/11/23 but has since been located on 02/16/23. Interview on 02/16/23 at 2:09 P.M. with Therapy #533 revealed the purpose of the cervical collar was to keep the neck in neutral position, to help loosen up the contracture, and to help with positioning while eating and wearing the cervical collar was beneficial for Resident #1. 366281 Page 13 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/16/23 at 5:06 P.M. with family of Resident #1 voiced Resident #1 wasn't wearing the cervical collar during visit on 02/14/23 and felt the collar was beneficial for his neck. Interview on 02/21/23 at 10:30 A.M. with the Director of Nursing (DON) confirmed Resident #1's cervical collar was unable to be located recently and as a result Resident #1 did not wear the cervical collar while it was unable to be located. The DON voiced the cervical collar helped with Resident #1's comfort level. Review of facility policy titled Positioning the Resident, revised January 2014, revealed the equipment would be used as necessary to maintain resident in good body alignment. 366281 Page 14 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

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 to ensure the environment was free from accidental hazards, and Residents #2, #4, and #65 received adequate supervision and services to prevent accidents. This affected three residents (Residents #2, #4, and #65) of four residents reviewed for accidents. The census was 82. Findings include: 1. Resident #65 was admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified dementia, muscle wasting and atrophy, general anxiety and major depressive disorder. Review of physician orders revealed an order for the resident to ambulate with supervision and no assistive device, and a Wanderguard to the right ankle. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 01/01/23 revealed Resident #65 was severely cognitively impaired, exhibited wandering behavior and ambulated independently. Review of the care plan of 01/01/23 revealed care areas included risk for elopement as evidenced by exit-seeking, intruding on the privacy or activities of others, physical aggression with care and medication refusal. Review of progress notes of 10/12/22 and 12/21/22 revealed Resident #65 was found by staff drinking peri-wash. It was unknown which room she had gotten the peri-wash from or how much she had ingested on both dates. Multiple observations from 02/13/23 06:38 P.M. to 02/16/23 at 8:35 A.M. revealed Resident #65 wandered throughout the secured unit, in and out of several other resident rooms unsupervised. Interview on 02/15/23 at 05:23 P.M. with Licensed Practical Nurse (LPN) #501 verified Resident #65 is at times a problem due to her wandering and intrusion into other residents' rooms. She had taken numerous items from these rooms including clothing, eyeglasses and TV remote controls. The LPN revealed a box of remotes for all the residents' TVs which were kept at the nurse station and residents needed to request their remote when needed. She also revealed a number of pairs of eyeglasses in a drawer at the nurse station which Resident #65 had collected and it was not known to whom they belonged. Observations on 02/16/22 from 10:28 A.M. to 10:38 A.M. on the secured unit revealed 16 bottles of Perifresh (perineal cleanser with aloe vera) unsecured in bathrooms or on top of resident dressers in 12 of the 16 rooms checked in the secured unit. The bottles contained a warning to keep out of the reach of children. Interview on 02/16/23 at 10:40 A. M. with LPN #313 verified the Perifresh was not secured in residents rooms and should have been locking in the top drawer of each resident's nightstand. Interview on 02/16/23 at 11:45 AM with the Poison Treatment and Advice Hotline Central Ohio (1-800-222-1222) revealed ingestion of Perifresh will produce gastrointestinal symptoms such as nausea, 366281 Page 15 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vomiting and abdominal discomfort with oral exposure. Most symptoms are seen due to chronic use. Toxicity would be observed after ingestion of one gram/day over several days. Significant toxicity not likely. Aloe may produce cathartic effects following oral use and/or exposure. Interview on 02/16/23 12:07 P.M. with Quality Assurance (QA) Nurse #603 verified the Perifresh should not have been out in resident rooms. The facility did a QA project after the first incident of ingestion on 1012/23. She was unable to explain how the second incident of ingestion occurred. She also veiled Resident #65 was for the most part, non-verbal but could answer yes or no questions. 2. Review of the medical record for Resident #2 revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, intermittent explosive disorder and anxiety. Review of Resident #2's quarterly MDS of 11/25/22 revealed the resident was severely cognitively impaired, and required extensive assist of one for activities of daily living. Review of care plan of 11/25/22 revealed care areas included impaired cognition, risk for elopement as evidenced by becoming exit seeking; risk of getting outside the facility and/or significantly intrudes on the privacy or activities of others, difficulty with communication related to impaired cognition and hearing. Resident was rarely understood and rarely understands, Review of the Performance Improvement Project (PIP) dated 01/16/23, provided by the facility, revealed Resident #2 was observed by staff attempting to place objects into the electrical outlets on multiple occasions. The PIP goal was to place outlet covers into all electric outlets in common areas, hallways and accessible outlets in the south activity room. Observation on 02/16/23 at 12:57 P.M. and interview with LPN #313 verified that while the outlets were covered in the common areas and hallways, the outlets in Resident #2's room. were not, but should be covered. The room included two outlets approximately four feet off the ground and easily accessible as well as outlets in the usual low position. Interview on 02/22/23 at 10:30 A.M. with QA Nurse #603 verified Resident #2 was observed trying to place objects into the outlets in the common area. The outlets in her room were not covered due to the resident not getting out of her wheelchair much anymore. 3. Review of medical record for Resident #4 revealed an admission date of 12/06/22 and diagnoses included urinary tract infection, chronic pain syndrome, generalized anxiety disorder, abnormalities of gait and mobility, osteoporosis, and repeated falls. Review of 12/29/22 five day Minimum Data Set (MDS assessment) revealed Resident #4 was moderately impaired cognitively, required extensive assistance of two people for bed mobility, transfers, dressing and toileting, and required extensive assistance of one person for locomotion on and off unit and personal hygiene. Review of falls risk assessment dated [DATE] revealed Resident #4 was high risk for falls. Review of care plan initiated 12/15/22 revealed Resident #4 was at risk for falls related to muscle wasting and atrophy, abnormal posture, abnormalities in gait and mobility, repeated falls, and 366281 Page 16 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few osteoporosis with interventions which included keep call light and most frequently used personal items within reach, ensure shoes are well fitting with nonslip soles, and nonskid rug to bathroom in front of toilet and to exit side of bed. Review of Resident #4's physician orders revealed an order dated 01/19/23 for a mattress to exit side of bed for safety precautions. Observation on 02/15/23 at 12:55 P.M. revealed Resident #4's call light was sitting on top of blanket at the end of the bed while Resident #4 was sitting across the room in her wheelchair. Housekeeper #567 at the time of observation confirmed the call light was not in reach of the Resident #4. Observation on 02/16/23 at 8:00 A.M. revealed Resident #4 was sleeping in bed. Blue mat was observed leaning up against the unoccupied bed across the room. Interview on 02/16/23 at 8:03 A.M. with State Tested Nursing Assistant (STNA) #441 confirmed the mat was leaning up against the unoccupied instead of on the floor next to the exit side of the bed and immediately moved it to the correct area. Review of facility policy titled Fall Prevention and Fall Management Policy, reviewed March 2022, revealed fall management would include development of a care plan with interventions, interventions would be evaluated for effectiveness, ordered devices would be in place and in good working order, and call lights would be within reach. 366281 Page 17 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure effective treatment and services were in place to ensure residents with dementia maintained their highest practical well-being. This affected two residents (Resident #65 and Resident #134) of four residents reviewed for behavior. The census was 82. Residents Affected - Few Findings include: 1. Resident #65 was admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified dementia, muscle wasting and atrophy, general anxiety and major depressive disorder. Review of physician orders included an order for the resident to ambulate with supervision and no assistive device, and a Wanderguard to the right ankle. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 01/01/23 revealed Resident #65 was severely cognitively impaired, exhibited wandering behavior and ambulated independently. Review of the care plan of 01/01/23 revealed care areas included risk for elopement as evidenced by exit-seeking, intruding on the privacy or activities of others, physical aggression with care and medication refusal. There was no mention of possible harmful behaviors such as ingesting non-food items. Review of progress notes of 10/12/22 and 12/21/22 revealed Resident #65 was found by staff drinking g peri-wash. It was unknown which room she had gotten the peri-wash from or how much she had ingested on both dates. Multiple observations from 02/13/23 06:38 P.M. to 02/16/23 at 8:35 A.M. revealed Resident #65 wandered throughout the secured unit, in and out of several other resident rooms unsupervised. Interview on 02/15/23 at 05:23 P.M. with Licensed Practical Nurse (LPN) #501 verified Resident #65 is at times a problem due to her wandering and intrusion into other residents' rooms. She had taken numerous items from these rooms including clothing, eyeglasses and TV remote controls. The LPN revealed a box of remotes for all the residents' TVs which were kept at the nurse station and residents needed to request their remote when needed. She also revealed a number of pairs of eyeglasses in a drawer at the nurse station which Resident #65 had collected and it was not known to whom they belonged. Observations on 02/16/22 from 10:28 A.M. to 10:38 A.M. on the secured unit revealed 16 bottles of Perifresh (perineal cleanser with aloe vera) unsecured in bathrooms or on top of resident dressers in 12 of the 16 rooms checked in the secured unit. The bottles contained a warning to keep out of the reach of children. Interview on 02/16/23 at 10:40 A. M. with LPN #313, who discovered Resident #65 drinking Perifresh on 10/12/22 verified the Perifresh was not secured in residents rooms and should have been locking in the top drawer of each resident's nightstand. Interview on 02/16/23 12:07 P.M. with Quality Assurance (QA) Nurse #603 verified the Perifresh 366281 Page 18 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should not have been out in resident rooms. The facility did a QA project after the first incident of ingestion on 1012/23. She was unable to explain how the second incident of ingestion occurred. She also veiled Resident #65 was for the most part, non-verbal but could answer yes or no questions. She verified the care plan did not include the history of ingesting peri-wash. The facility was unable to provide a specific behavior management policy, but did provide a cop of the undated Alzheimer Association (AA) Suggestions for Responding to Dementia Related Behaviors and the March 2022 AA Dementia Training for Direct Care Workers. 2. Review of the medical record for Resident #134 revealed the resident was admitted to the secured unit on 01/25/23 with diagnoses including Alzheimer's disease with late onset, dementia, unspecified severity, with other behavioral disturbance, cognitive communication deficit, and prostatic hyperplasia. Review of the Medicare 5-day MDS 3.0 of 01/31/23 revealed Resident #134 was severely cognitively impaired, exhibited physical behaviors towards others, rejection of care and wandering, required extensive assist of one for activities of daily living (ADL), required supervision/limited assist for walking, and was frequently incontinent of bladder. The resident was not on a toileting program. Resident #134's care plan of 01/26/23 revealed care areas for cognition, difficulty with communication related to Alzheimer's disease and dementia, rarely understands and was rarely understood, incontinence and behaviors of rejection of care and wandering. There was no mention of urination in inappropriate places. Review of Resident #134's 01/31/23 progress notes revealed the nurse was alerted by a family member that Resident #134 was in another resident's room. Upon entering room Resident found with his hands in his pants sitting on another resident's bed. The nurse was able to escort the resident out of the room. The physician ordered Zyprexa (an anti-psychotic). Review of progress notes of 02/06/23 revealed Resident #134 walked into another room, pulled his pants down and urinated on the floor. He refused to let staff put on clean dry pants or do peri-care. Review of the progress note of 02/14/23 revealed Resident #134 wandered went into another resident's room and urinated on the floor. The incident was reported by a family member of a third resident. Observation on 02/15/23 at 7:54 A.M. revealed Resident #134 walked out of his room and urinated all over the floor in the hallway. He was redirected back into his room by staff. Interview on 02/15/23 at 5:23 P.M. with Licensed Practical Nurse (LPN) #314 revealed the LPN was not aware of the incident with Resident #134 earlier in the day. Staff usually reported behaviors to the nurses and they were logged on the behavior tracking for each resident. She verified Resident #134 had urinated in inappropriate places previously and staff should be monitoring him for toileting. Interview on 02/16/23 at 8:41 A.M. with State Tested Nursing Assistant (STNA) #413 verified she witnessed Resident #134 urinating on the floor the previous day but did not document the behavior or tell the nurse. She revealed she had not received any training on dealing with behaviors. Interview on 02/21/23 at 11:47 A.M. with Restorative Nurse (RN) #605 verified Resident #134 had instances of urinating in inappropriate places, was not on a toileting program, but may benefit from a 366281 Page 19 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0744 toileting program. Level of Harm - Minimal harm or potential for actual harm The facility was unable to provide a specific behavior management policy, but did provide a copy of the undated Alzheimer Association (AA) Suggestions for Responding to Dementia Related Behaviors and the March 2022 AA Dementia Training for Direct Care Workers. Residents Affected - Few 366281 Page 20 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 2. Resident #15 was admitted on [DATE] with diagnoses including schizophrenia, extrapyramidal disorder (involuntary muscle movements often caused by antipsychotic medications), and mild cognitive impairment. Review of physician orders included an order for Risperidone (anti-psychotic medication) 3 mg. Review of the annual Minimum Data Summary (MDS) 3.0 of 01/10/23 for Resident #15 revealed the resident was cognitively intact, required extensive assist of two for ADLs, and received antipsychotics. Review of the care plan of 01/10/23 revealed care areas included use of psychotropic medications with interventions including monitoring for interactions with other medications and adverse reactions. Review of Resident #15's medical record revealed no evidence an AIMS assessment had not be completed in the last six months. Interview on 02/21/23 at 9:38 A.M. with the DON revealed the facility had not done AIMS assessments for almost three years due to changes in nursing administration and the pandemic. Review of a list of residents on anti-psychotics revealed 13 residents (Resident #15, #22, #24, #25, #29, #34, #49, #52, #61, #65, #71, #72, and #134) received anti-psychotic medication. Review of facility policy titled Psychotropic Medications revised October 2017, included AIMs testing would be done every six months on residents receiving an antipsychotic medication. Any findings indicating a possible movement disorder would be reviewed with the attending physician or psychiatrist. Review of facility policy titled Psychopharmacological Medication Documentation, dated August 2018, revealed the facility would be monitored and documenting resident's response to psychopharmacological medication administration and assessment of side effects in order to assess therapeutic value of therapy. Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident's #15 and #25 were monitored for antipsychotic medication side effects. This affected two residents (Resident's #15 and #25) and had the potential to affect all 13 residents (Resident #15, #22, #24, #25, #29, #34, #49, #52, #61, #65, #71, #72, and #134) on antipsychotic medications. The facility census was 82. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 08/13/20 and diagnoses included Alzheimer's Disease, type two diabetes mellitus, dementia and dysphagia. Review of Resident #25's physician orders dated, 07/15/22, revealed Risperidone (anti-psychotic medication) tablet 0.25 milligram (mg), give one tablet by mouth at bedtime related to Alzheimer's Disease, dementia with behavioral disturbance. 366281 Page 21 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #25's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #25 had severe cognitive impairment. Resident #25 required extensive assistance of two staff members for bed mobility, had total dependence of two staff for transfers and toilet use, and was always incontinent of urine and bowel. Resident #25 received antipsychotic medication. Review of Resident #25's psychiatric progress notes dated 07/15/22, revealed a gradual dose reduction of Risperidone for Resident #25 had been attempted in the past (03/2022), failed and had to be restarted in 07/2022. Review of Resident #25's medical record including evaluations and progress notes from 08/19/22 through 02/20/23 did not reveal an AIMs (Abnormal Involuntary Movement Scale) evaluation was completed. Interview on 02/21/23 at 9:32 A.M. with the Director of Nursing revealed Resident #25 was not always responsive to hands on care, still had behaviors like throwing legs over chairs. The DON stated Resident #25 was able to be redirected much better now. Observation on 02/16/23 at 2:00 P.M. revealed Resident #25 was in a padded wheelchair in the common area and was lying quietly. Interview on 02/21/23 at 9:38 A.M. with Registered Nurse/MDS Nurse (RN/MDS) #607 revealed the MDS Nurses did not do AIMs (Abnormal Involuntary Movement Scale) assessments and she thought the Director of Nursing did the AIMs assessments. RN/MDS #607 stated she had not done any AIMs assessments on the residents. Interview on 02/21/23 at 9:39 A.M. with the Director of Nursing revealed she did not do AIMS assessments, and thought the MDS Nurses did them. The DON stated she guessed they have not been done. Review of facility policy titled Psychotropic Medications revised, 10/2017, included AIMs testing would be done every six months on residents receiving an antipsychotic medication. Any findings indicating a possible movement disorder would be reviewed with the attending physician or psychiatrist. 366281 Page 22 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy, the facility failed to ensure the kitchen area was maintained in a clean and sanitary condition and food items were properly dated. This had the potential to affect all 82 of 82 residents who consumed food items from the kitchen. Findings include: Observation of the kitchen on 02/12/23 from 6:26 P.M. to 6:48 P.M. with Dietary #518 revealed: • The stand mixer was observed to uncovered and had five spots of dried brown debris on the base and underside of the unit. • In the dried storage area was observed to be one opened half full bag of penne pasta resealed in a one storage bag undated; one fourth full bag of white cake mix opened and resealed in a storage bag undated; one half bag of bow tie pasta opened and resealed in a storage bag undated; one three fourth full bag of multi colored spiral rotini resealed in a storage bag undated; and one fourth full bag of cornflakes resealed in a storage bag undated. • In the walk-in cooler, one dried red colored drip of liquid was observed down the support pole of the shelving unit and multiple red colored dried liquid spills were observed on the left sided shelving unit. There were observed to be two individual margarine packets and one individual sealed orange juice cup and other built up debris under all of the shelving units. • In the walk-on freezer was observed to be one half full bag of breaded eggplant opened and resealed in a storage bag undated. Under all shelves was a built up of debris, which included one sealed sherbet cup. • Observation of the exhaust hood filters above the oven revealed a buildup of dust. • Observation of the wall fans above the three compartment sink and both handwashing sinks revealed a buildup of dust on the fan blades and visible strings of dust blowing from the metal cages around the fan blades. During the time of observation on 02/13/23 from 6:26 P.M. to 6:48 P.M., Dietary #518 confirmed the areas of concern. 366281 Page 23 of 24 366281 02/23/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 02/14/23 at 9:50 A.M. with Dietitian #538, Dietary #513, and Corporate Nutrition #541 confirmed they were aware of the results of the kitchen tour on 02/13/23 and many of the concerned areas had already been corrected and a cover for the mixer had been ordered. Review of facility policy titled Covering, Labeling, and Dating Food, revised April 2014, revealed items would be marked with the date opened. Review of facility policy titled Freezer Floor Cleaning, dated October 2017, revealed the walk-in freezer and walk-in cooler would be swept, mopped, and debris would be picked up. Review of facility policy titled Food Safety and Sanitation, revised February 2023, revealed unprotected equipment could be a source of contamination and a potential cause of foodborne outbreaks, and fixed equipment, which included mixers, would be washed and sanitized. 366281 Page 24 of 24