Health inspection·October 17, 2019

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 observation, interview and record review, the facility failed to ensure the resident's guardian was notified when a x-ray was ordered due to pain. This affected one resident (Resident #13) of one resident reviewed for change of condition. The facility census was 68. Findings Include: Resident # 13 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dysphagia, osteoporosis with pathological fracture left humerus, lump in breast, dementia, depression, anxiety, history of cerebrovascular disease. Resident #13 daughter was identified as her responsible party. The quarterly Minimum Data Set completed on 07/22/19 indicated severe cognitive delay and Resident #13 required extensive assistance with activities of daily living. Review of the nursing progress note dated 09/11/19 at 2:15 P.M. indicated Resident #13 was not feeling well with rhonchi noted in bilateral lower lobes and mild aches and pain to which Tylenol was effective. The Nurse Practitioner (NP) was notified and ordered a chest x-ray and laboratory tests. The resident and responsible party were notified. On 09/12/19 at 12:14 P.M., the nursing progress notes indicated a bruise was noted to resident left upper extremity and resident exhibited non verbal signs of pain. The NP was notified and ordered a x-ray to the left upper extremity. A nursing progress note on 09/12/19 at 6:30 P.M. indicated the x-ray results were back and identified a fracture of the left humerus. The NP was made aware and a new order was given to immobilize the left arm and increase Tylenol to 1000 milligrams(mg) four times daily and to follow up with an orthopedic physician as resident is not a candidate for surgery due to age and diagnosis. A progress note on 09/14/19 at 1:33 P.M. indicated Resident #13 daughter was informed about resident's chest x-ray results and a new order for Lasix (a diuretic), and results of x-ray of left arm and new order for sling to immobilize the extremity. The nursing note indicated Resident #13 daughter was upset for not informed about this matter sooner. The nursing note indicated the nurse apologized for all. On 10/16/19 at 5:46 P.M. during an interview with Licensed Practical Nurse (LPN) #518, she reported the family or guardian should be notified of any change in a residents condition, fall, skin tear, orders for laboratory work or x-rays, and medication changes. LPN #518 stated she was aware of an Page 1 of 14 366367 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident when Resident #13 family was not notified in a timely manner of changes in her condition and the family was upset. LPN #518 stated all notification would be documented in the progress notes. Review of the facility policy Change in the Residents Condition of Status, dated 11/2016 indicated the nurse would immediately notify the physician and the resident's authorized representative when there is a change in the resident's condition. 366367 Page 2 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a safe environment was maintained for all residents. This affected one resident (Resident #58) when the facility failed to follow recommendations after the resident received a chemotherapeutic medication. The facility census was 68. Findings Include: Resident # 58 was admitted to the facility on [DATE] with diagnoses including multiple myeloma not having achieved remission, pain in right hip, pathological fracture pelvis, wedge compression fracture of fourth lumbar vertebra, hypertension, diabetes mellitus,Type II, obesity and depression. Review of the admission Minimum Data Set (MDS) completed on 08/09/19 indicated Resident #58 had no cognitive delay. The MDS indicated Resident #58 required extensive assistance with bed mobility, transfer, toileting and personal hygiene of two plus assistance. The MDS identified Resident #58 received chemotherapy while a resident at the facility. A review of Resident #58 medical record revealed she was seen by a palliative care cancer specialist on 08/26/19 and returned to the facility. Resident #58 medical record included an after visit summary dated 08/26/19 which indicated she had received Velcade, an anti-cancer medication used to treat relapsed multiple myeloma and mantle cell lymphoma. The after visit summary included 'How to Care for Yourself at Home after your Chemotherapy/Immunotherapy Treatment' which included: 1. For 48 hours after infusion in complete, close the lid on the toilet and flush twice, wash your hands with soap and water after each time you use the toilet. 2. Precautions should be used anytime you come in contact with body waste which included touching toilets, bedside commodes, vomit pans, urinals, ostomy bags, incontinence pads, adult diapers which include wear disposal gloves when handling any body waste, empty containers of body waste into the toilet close to the water to avoid splashing, put the lid down and flush the toilet two times. Clean body waste containers after each use with soap and water, rinse well. 3. Gloves should be worn to handle soiled laundry and placed in plastic bag. Laundry should be washed separately, using normal detergent and on the hot water cycle. The Plan of Care (POC) for Resident #58 dated 08/14/19 indicated potential for complications related to chemotherapy. The POC did not identify the precautions required in the after visit summary. Review of the nursing progress notes did not identify Resident #58 was seen by the palliative care cancer specialist nor identify the precautions required after receiving Velcade. On 10/16/19 at 3:35 P.M. during an interview with Registered Nurse (RN) #325 reported she was not aware of any precautions regarding Resident #58 after receiving any chemotherapy medication. On 10/16/19 at 3:42 P.M. the Director of Nurses (DON) and Regional Nurse, RN #370 reported she was 366367 Page 3 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not aware of Resident #58 receiving any type of chemotherapy medication by infusion since a resident at the facility. The DON and RN #370 stated the information provided on 08/26/19 from the palliative care visit was in reference to future infusions, which did not occur. The DON reported Resident #58 was started on oral chemotherapy medication while at the facility. On 10/17/19 at 8:52 A.M. during a phone interview with the infusion center, they confirmed Resident #58 was seen on 08/26/19 for an infusion of Velcade and was discharged with the after visit summary which include discharge instructions. State Tested Nurse Aide (STNA) #501 reported on 10/17/19 at 10:00 A.M. she routinely worked with Resident #58 and was not aware of any type of precautions in place since resident was admitted to the facility. On 10/17/19 at 2:51 P.M. during tour of laundry area with Housekeeper #521 she reported all laundry was removed from bags and placed together when sorting. Housekeeper #521 reported only laundry placed in isolation bags remained in the bag when placed in the washing machine and was washed separate from regular laundry on the isolation setting for detergent and water temperature. On 10/17/19 at 4:16 P.M. RN #370 confirmed the facility had contacted the palliative care center and Resident #58 did receive an infusion of Velcade on 08/26/19. RN #370 and the DON confirmed no precautions were followed after Resident #58 received the chemotherapeutic medication and Resident #58 had been placed on any type of secretion precautions. Review of the Occupational Health and Safety Administration, Controlling Occupational Exposure to Hazardous Drugs identified Human Effects of 1) cytogenetic effects (chromosomal damage), 2) reproductive effects, 3) cancer, and 4) other effects such as nausea and vomiting, skin rashes and hair loss. Antineoplastic medications are known to be toxic to the skin and mucous membranes. 366367 Page 4 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide written notification at the time of transfers. This affected three (Resident #36, Resident #38, and Resident #218) of five residents reviewed for hospitalizations. The census was 68. Findings Include: 1. Resident #36 was admitted to the facility on [DATE]. Her diagnoses were encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, Charcot's joint (left ankle/foot), type II diabetes, hyperlipidemia, muscle weakness, short Achilles tendon, difficulty walking, hypertension, anemia, osteoarthritis, migraines, cellulitis of left and right lower limb, pyogenic arthritis, phlebitis and thrombophlebitis, and calculus of gallbladder. Her Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact. The assessment was completed on 09/23/19. Review of Resident #36 medical records revealed she was admitted to the hospital on [DATE] for appropriate medical issues that could not be addressed in the facility. In review of her medical records, there was no documentation to support the resident and/or representative received written notification about the bed hold procedures at the time of discharge. 2. Resident #38 was admitted to the facility on [DATE]. Her diagnoses were aftercare of joint replacement surgery, dislocation of right hip, muscle weakness, anemia, hyperlipidemia, chronic obstructive pulmonary disease, hypertensive chronic kidney disease, hypocalcemia, chronic kidney disease (stage III), weakness, hypoxemia, hypokalemia, atherosclerotic heart disease, delirium, abnormalities of gait and mobility, difficulty walking, osteoarthritis, dementia, aortocoronary bypass graft, major depressive disorder, primary generalized osteoarthritis, dorsalgia, psoriasis, sensorineural hearing loss, wheezing, insomnia, and cerebral infarction. Her BIMS score was 13, which indicated she was cognitively intact. The assessment was completed on 09/30/19. Review of Resident #38 medical records revealed she was admitted to the hospital on [DATE] for appropriate medical issues that could not be addressed in the facility. In review of her medical records, there was no documentation to support the resident and/or representative received written notification about the bed hold procedures at the time of discharge. 3. Resident #218 was admitted to the facility on [DATE]. His diagnoses were aftercare following joint replacement surgery, fracture of unspecified part of neck of right femur, acute respiratory failure, type II diabetes, muscle weakness, heart failure, need for assistance with personal care, dysphagia, chronic obstructive pulmonary disease, atherosclerotic heart disease, acute pulmonary edema, peripheral vascular disease, osteoarthritis, thrombocytopenia, history of falling, hypoglycemia, hyperlipidemia, hypertension. carotid artery syndrome, obstructive sleep apnea, major depressive disorder, mood disorder, anorexia, insomnia, hearing loss, anemia, and atrial fibrillation. His BIMS score was 13, which indicated she was cognitively intact. The assessment was completed on 09/13/19. Review of Resident #218 medical records revealed he was admitted to the hospital on [DATE] and 10/15/19 for appropriate medical issues that could not be addressed in the facility. In review of his medical records, there was no documentation to support the resident and/or representative received 366367 Page 5 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0625 written notification about the bed hold procedures at the time of both discharges. Level of Harm - Minimal harm or potential for actual harm Interview with Administrator on 10/16/19 at 4:45 P.M. and 5:23 P.M. revealed they could not find evidence that the bed hold notification had been given to each resident at the time of their discharges. She confirmed they will start do this with all residents, including those that do not have Medicaid insurance/services. Residents Affected - Few Review of the facility, Bed Hold Days policy (dated October 2018) revealed, The facility will provide to the resident and the resident representative at the time of transfer of a resident for hospitalization or therapeutic leave, a written notice which specifies the duration of the bed-hold policy. All residents who are transferred to an acute care hospital or take a therapeutic leave will receive a written notice of the bed hold policy. 366367 Page 6 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff and resident interview, the facility failed to provide activities of daily living for residents unable to carry out these activities. This affected three of seven residents reviewed for activities of daily living. (Residents #2, #16 and #272). The facility census was 68. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed the resident was admitted on [DATE] with diagnoses to include diabetes mellitus type 2 and dementia. Review of the care plan dated 04/30/18 and shower book revealed the resident was to get a shower twice a week on Wednesday and Saturday. She was noted to need extensive assist of 1 for nail care and bathing. The shower records indicated the resident did not receive a shower or bath on 10/12/19. On 10/16/19 the record indicated the resident had a bed bath and not a shower and the nails were documented as being cleaned. Observation and resident interview on 10/15/19 at 10:51 A.M. revealed the resident had dirty hair, appearing greasy and dirty nails. Observation on 10/17/19 at 7:37 A.M. resident nails were long and dirty, Licensed Practical Nurse (LPN) #534 confirmed the dirty nails and stated she would get them cleaned today. Observation on 10/17/19 at 8:59 A.M. revealed the resident had greasy hair and dirty nails. Interview with the Director of Nursing on 10/16/19 at 4:42 P.M. confirmed the aides were documenting providing nail care when the resident's nails were found to be long and dirty. 2. Review of the medical record for Resident #16 revealed an admission date of 3/23/18 with diagnoses to include Clostridium Difficile. Review of the care plan revealed the staff were to provide nail care and shampoo hair with showers per weekly schedule. Groom hair daily and encourage resident to participate as able. Provide/assist with morning and evening care, encourage resident to participate with hygiene as tolerated. Review of the shower book revealed Resident #16 was provided bed baths instead of showers in the month of 09/19 and 10/19. Fingernails were documented as being trimmed and cleaned on all but one time on 09/17/19. Observation on 10/15/19 at 11:53 A.M. residents nails were noted to be unclean and dirty. Interview with the Director of Nursing on 10/16/19 at 4:42 P.M. stated she looked at the residents nails and they are long and not clean. She stated even though the nurse aide documented they had performed nail care, they probably just cleaned them in the shower. The residents record revealed the resident is given a bed bath, not showers. 3. Resident # 272 admitted to the facility on [DATE] with diagnoses including status post back surgery, spinal stenosis, hypertension, scoliosis, and history of hip and knee replacement. 366367 Page 7 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The initial care plan for Resident #272 identified she would receive assistance with all activities of daily living. Review of the shower sheet schedule for the 200 Hall indicated Resident #272 was to receive a shower on Tuesday and Friday during the 7-3 shift. Review of the bathing/skin tool for Resident #272 indicated she was bathed on 10/11/19 (Friday), four days after admission. There was not indication Resident #272 was offered a shower/bath on Tuesday, 10/08/19. During an interview on 10/15/19 at 10:32 A.M. Resident #272 family member reported the resident was not offered a shower for several days after admission, even though she and Resident #272 had asked for a shower. Licensed Practical Nurse (LPN) #355 reported on 10/17/19 at 2:57 P.M. residents were to be bathed per the schedule for the hall. LPN #355 stated staff were to inform the nurse if they were unable to complete the scheduled bathing schedule, or if a resident refused. LPN #355 reported staff did not always sign the bathing/skin tool records During an interview on 10/17/19 at 3:14 P.M. with State Tested Nurse Aide (STNA) #503 she stated the facility tried to make sure showers were given per schedule, however if a resident was new and required extra assistance, they may not be able to get their shower when scheduled. STNA #503 stated she would tell the oncoming staff of any missed showers, and they would attempt to complete them on their shift. STNA #503 stated all showers or bed baths were to be documented on the shower/skin tool when administered. STNA #503 stated she did not always report not being able to complete showers to the nurse, and was unaware if this was required. 366367 Page 8 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

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 residents were provided care to ensure safety. This affected two residents, one resident (Resident #58) who was not transferred per policy with a mechanical device, and one resident (Resident #63) who did not have fall precautions in place out of three residents reviewed for accidents. The facility census was 68. Findings Include: 1. Resident # 58 was admitted to the facility on [DATE] with diagnoses including multiple myeloma not having achieved remission, pain in right hip, pathological fracture pelvis, wedge compression fracture of fourth lumbar vertebra, hypertension, diabetes mellitus,Type II, obesity and depression. Review of the admission Minimum Data Set (MDS) completed on 08/09/19 indicated Resident #58 had no cognitive delay. The MDS indicated Resident #58 required extensive assistance with bed mobility, transfer, toileting and personal hygiene of two plus assistance. The MDS identified Resident #58 received chemotherapy while a resident at the facility. Review of the Plan of Care dated 08/14/19 for Resident #58 identified she required two person assistance with all activities of daily living. The physician orders revealed on 09/20/19 the physician ordered to monitor the raised area on top of head daily until resolved, cleanse skin tear on R lower leg with normal saline, pat dry and cover with clean dry dressing daily and as needed. A review of the nursing progress notes on 09/20/2019 at 2:44 P.M. indicated the nurse was notified by a State Tested Nurse Aide (STNA) that while she was transferring resident with a Hoyer lift, the lift tipped and hit the resident on the head and scratched her leg. The nursing progress note indicated that upon entering the room, Resident #58 was noted to be sitting in a wheelchair. A skin tear was noted to the right lower leg and the leg was bleeding. The area was cleansed with normal saline and a clean dry dressing was applied. Resident #58 reported the Hoyer lift hit her on the head and a know was noted. The nursing progress note indicated a large raised area was noted on the left side of the residents head under her hair. No discoloration was noted. The physician and responsible party were notified. A interdisciplinary team (IDT) progress note dated 09/24/19 at 9:00 A.M. indicated the IDT met to review the incident on 09/20/19. The progress note indicated Resident #58 was being transferred by a STNA by a mechanical lift from the bed to wheelchair. Upon transfer, the STNA stated Resident #58 started to suddenly lower. The STNA stated she initially thought that the mechanical lift was tipping over so she braced the mechanical lift, The STNA stated this occurred while the patient was in the wheelchair but indicated that there was still tension on the straps of the mechanical lift. The STNA ensured the patient's safety and the nurse was immediately notified. The nurse entered the patients room and assessed from head to toe, identifying a skin tear to the right lower leg and patient presented with hematoma to the top of her head. Resident #58 denied any pain, no change in range of motion and no loss of consciousness were identified. Neurological checks were initiated and remained within normal limits. The skin tear to the right lower extremity was cleansed with wound cleanser, applied treatment applied per physician order. The hematoma would be continually monitored until 366367 Page 9 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resolved. Maintenance was notified and requested to evaluate the lift before it was used by any other patients. Upon further discussion with the STNA and Resident #58, it was determined that likely cause of the mechanical lift dropping as it did was because upon transferring the patient into the wheelchair, the patients leg had came in contact with the emergency drop button, causing the skin tear on the right leg and also causing the lift to drop. The top of the mechanical lift arm came in contact with the top of the patients head causing the hematoma. Maintenance indicated that upon inspection, the lift was functioning in correct order. The STNA involved in the transfer was educated to be aware of the emergency drop lever to ensure that patient does not come in contact with the lever to prevent further occurrences. The patient, responsible party and MD aware of all information and agree with the plan of care. On 10/16/19 at 3:35 P.M. Registered Nurse (RN) #325 stated she was informed Resident #58 had hit her head and received a skin tear to her leg while being transferred with a Hoyer lift. RN #325 reported the area to the leg had healed, and no concerns were identified with the hematoma to the head. RN #325 reported the hematoma had basically resolved at this time. The Director of Nurses (DON) reported on 10/16/19 at 3:42 P.M. Resident #58 had hit her head on a Hoyer lift during transfer. The DON confirmed the documentation indicated one staff was present during the transfer of Resident #58 with the Hoyer lift. The DON reported the resident did not fall during the incident and had no further concerns. STNA #501 reported on 10/17/19 at 10:00 A.M. Resident #58 required a Hoyer lift with all transfers. STNA #501 reported she could only speak for herself, however she would never transfer a resident without two people present to assist when using a Hoyer lift. On 10/17/19 at 10:12 A.M., STNA #321 stated two people were always to be present any time a Hoyer lift or sit to stand was used when transferring a resident. Physical Therapy Assistant (PTA) #371 and Certified Occupational Therapy Assistant (COTA) #372 stated on 10/17/19 at 11:17 A.M. any time any type of mechanical devise including a Hoyer lift was used to transfer a resident, two people were to be present to assist with the transfer. They stated the therapy department routinely provided training for staff in use of a Hoyer lift. Review of facility policy 'Hoyer Lift Guidelines,' no date, indicated to always have two staff members present when using the Hoyer lift. The user manual for Reliant 450 Hoyer lift indicated the company recommended two assistants be used for all lifting preparation, transferring from and transferring procedures. 2. Resident #63 was admitted to the facility on [DATE]. His diagnoses were spinal stenosis (cervical region), cervical disc disorder with myelopathy, hyperlipidemia, chronic respiratory failure, type II diabetes, hypertension, muscle weakness, chronic kidney disease (stage III), difficulty walking, chronic obstructive pulmonary disease, difficulty in walking, anemia, need for assistance with personal care, chronic neck and back pain, hypo-osmolality and hyponatremia, retention of urine, repeated falls, hypokalemia, major depressive disorder, restless leg syndrome, idiopathic peripheral autonomic neuropathy, insomnia, and constipation. His Brief Interview for Mental Status (BIMS) score was 13, which indicated he was cognitvely intact. The assessment was completed on 10/04/19. Review of Resident #63 medical records revealed he was admitted to the facility after having neck 366367 Page 10 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few surgery and had a neck brace to wear at all times. In review of his electronic progress notes and incident report (dated 09/20/19), he was found on the floor after an unwitnessed fall; he was attempting to ambulate without assistance. After completing a thorough assessment after the fall, it was determined the resident had some skin tears and a laceration to the bridge of his nose. He did not have non-skid footwear on and there were no other fall interventions put in place. When reviewing his fall assessment and baseline care plan that was done immediately upon admission (no date listed on the document), it revealed that he was deemed not to be a fall risk. The fall assessment/baseline care plan did not document that he had an orthopedic functional limitation and did not capture that he was on an anti-depressant at the time of the assessment. Finally, according to the hospital therapy records prior to the admission to the facility, it confirmed that the resident was a fall and injury risk due to his neck surgery. This was the reason why the facility did not have any fall interventions in place at the time of Resident #63 fall, when there should have been due to his admitting diagnoses and limitations. Interview with Director of Nursing (DON) on 10/17/19 at 2:23 P.M., 2:47 P.M., and 3:17 P.M., confirmed Resident #63 fell on [DATE] and there were no fall interventions in place due to being assessed as a non-fall risk. She confirmed she would have assessed Resident #63 as a fall risk upon admission due to his admitting diagnoses and functional limitations. 366367 Page 11 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, and staff interview, the facility failed to follow appropriate antibiotic stewardship guidelines regarding monitoring symptoms of infections for continued antibiotic use. This affected one (Resident #16) of two residents reviewed for isolation precautions. The census was 68. Residents Affected - Few Findings Include: Review of the medical record for Resident #16 revealed an admission date of 03/23/18 and diagnoses to include clostridium difficile (C-diff). Review of the care plan on 05/21/2019 revealed the resident had infection of C-diff with a goal that included to have the infection resolved without complications. Interventions included to administer medications as ordered, observe and report any adverse side effects. Obtain and report diagnostic testing and laboratory results per order, obtain vital signs as ordered, staff to maintain contact precautions. The care plan did not include for staff to monitor bowel movements for diarrhea. Review of the physician's orders included Vancomycin ordered on 09/03/19, 125 milligram by mouth every other day with no stop date. Review of the nurse practitioner notes revealed on 09/03/19 the resident was seen, Vancomycin was changed to every other day with goal to discontinue the medication. (no date mentioned) Review of the bowel movement (BM) records revealed only the size of the BM was documented and whether the resident was continent or incontinent. The records did not indicate if the resident had diarrhea or formed stools. Review of the nurses progress notes revealed no evidence the staff were monitoring whether the resident was having loose or formed stools. The records reviewed revealed from 08/01/19 through 10/17/19 the staff had not documented the resident had any diarrhea throughout the time period. Interview on 10/15/19 at 12:05 P.M. with Resident #16 stated he has been in isolation for C-diff but the staff told him about a month ago he no longer has the C-diff but he was still in isolation and didn't know what was going on. Interview with the corporate nurse #601 on 10/17/19 at 9:51 A.M. stated the resident continues to have multiple episodes of stools per day and continues to have episode of incontinence. She admits there was no documentation of actual diarrhea and stated the nurse practitioner gets her information from talking with the staff. She stated the staff have no way to document formed stools versus diarrhea but admits the progress notes could contain this information but doesn't. She stated the Center for Disease Control (CDC) guidelines says if he continues to have greater than 3 stools a day to isolate the patient or if they have a history and he is having incontinent episodes. She confirmed there is no documentation as to whether the stools are loose or formed as they don't document this. She also confirmed the resident having formed stools is important to know to determine if the condition had improved. Review of a Clostridium difficile frequently asked questions from the CDC reveals isolation precautions should be continued until diarrhea ceases. 366367 Page 12 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and staff interview, the facility failed to provide a sanitary and comfortable environment for six, Residents #2, 8, 13, 16, 25 and 270, of 24 residents reviewed for environment. The facility census was 68. Findings include: 1. On 10/15/19 at 9:52 A.M. observation of Resident #13's bathroom revealed the walls were marred, the floor around the commode had rust stains and the privacy curtains were stained with brown areas noted toward the bottom of the curtain. 2. On 10/15/19 at 10:25 A.M. observation of Resident #25's floor around commode were rust stained. On 10/15/19 at 10:29 A.M. the call light was not in reach while resident sat in recliner chair. 3. On 10/15/19 at 10:39 A.M. observation of Resident #2's bathroom was dirty, toilet looked like it had dirt in it, toilet seat was dirty with brown particles present, rust colored stain and dirt was noted around the toilet. 4. On 10/15/19 at 11:51 A.M. observation of Resident #16's folding bathroom rails were dusty and rusty type substance was noted, the over the bed table was sticky with liquid. A document in a plastic sleeve was stuck to the table. 5. On 10/15/19 at 3:40 P.M. observation of Resident #270's walls were marred and in need of repair. 6. On 10/16/19 at 8:49 A.M. observation of Resident #8's floor had multiple areas of debris noted, scuffed with black marks on the floor, bathroom wall was marred - wall adjacent to door, plaster was partially repaired with spackling but was not sanded or painted. 7. On 10/16/19 at 8:42 A.M. observation of Resident #8 light cord at bedside was too long. Interview on 10/16/19 at 8:47 A.M. with the Director of Nursing confirmed the light cord at bedside was 366367 Page 13 of 14 366367 10/17/2019 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 'too long' and stated it would be a safety risk and confirmed the call light in bathroom did not have a cord and was not functioning. Walking rounds with the Administrator on 10/17/19 at 4:00 P.M. confirmed the above findings except for Resident #16. She stated the rust stains around the multiple toilets had tried to be clean in the past and was unsuccessful. She stated nothing had been done since that attempt. She stated she didn't know what caused it but thought it was a certain flooring in the bathrooms, but the rust stain was also found on a floor tile that was not the same flooring. She stated the floors probably needed replaced. 8. On 10/17/19 from 4:20 P.M. to 4:30 P.M. observation of Resident #16's handrails by the commode revealed a rust colored texture/discoloration on the rails. When touching the rail, an orange/brown color came off onto the surveyor's glove. This was confirmed by Maintenance Director #600. Also, the bedside table was dirty with dried food/liquid on the table as well as a plastic sleeve that contained important phone numbers. This was also confirmed by the Maintenance Director #600. 366367 Page 14 of 14