Health inspection·February 11, 2022

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and review of policy, the facility failed to conduct quarterly care conferences for one resident. The affected one (#65) of three residents reviewed for care conferences. The facility census was 91. Findings include: Review of the medical record for Resident #65 revealed an admission date of 05/06/20 with medical diagnoses that included urinary tract infection, major depressive disorder, anxiety disorder, and myasthenia gravis without acute exacerbation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] for Resident #65 revealed the resident had intact cognition on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the clinical census for Resident #65 revealed the resident had hospitalizations from 04/25/21 to 04/29/21, 10/15/21 to 10/19/21, 11/18/21 to 11/24/21, and 12/23/21 to 12/28/21. Review of the nurses notes from 04/15/21 to current revealed Resident #65 had a care conference on 04/14/21. On 06/23/21, the facility attempted to contact Resident #65's son for a quarterly conference and was unsuccessful. On 07/07/21, another attempted call was made to Resident #65's son for a quarterly care conference and was unsuccessful. There were no additional nurse's notes related to care conferences until 02/01/22, after the survey team entered, and a care conference was scheduled for 02/15/22. Review of the Interdisciplinary (IDT) Plan of Care Review Summary notes revealed a care conference was scheduled for 11/22/21 and 12/27/21 but were canceled due to Resident #65's hospitalizations. There was no evidence that a care conference had been scheduled and/or conducted from 04/14/21 to 11/22/21. Review of the plan of care date 05/06/20, and last revised on 11/15/21, revealed Resident #65 experienced an alteration in mood and/or behavior which included feeling tired or having little energy, poor appetite or overeating, and showed little interest or pleasure in doing things. Interventions included contact resident's family for support as needed and encourage loved ones to keep in contact/visit. Interview on 01/31/22 at 12:00 P.M., with Resident #65 revealed he had not had a care conference Page 1 of 28 366387 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0553 for a while. Level of Harm - Minimal harm or potential for actual harm Interview on 02/01/22 at 6:16 P.M., with Social Services Designee (SSD) #221 revealed she had been in her current position since July 2021. SSD #221 confirmed a quarterly care conference had not been conducted since 04/14/21. SSD #221 stated care conferences in November 2021 and December 2021 had been canceled due to the resident being ill. SSD #221 stated the resident was scheduled for a care conference on 02/15/22. Residents Affected - Few Review of the policy titled, Resident/Resident Representative Care Conferences, revised 05/09/18, stated, the resident and/or resident representative will be informed of a projected schedule for quarterly care conferences for the year and that they may request a care conference at any time. Furthermore, at routine intervals, and after significant changes, the resident and/or resident representative will be given an opportunity to have a care conference. 366387 Page 2 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, the facility failed to ensure a resident was provided with a bed mobility devices to assist with bed mobility. This affected one (#85) of one resident reviewed for bed mobility. The facility census was 91. Residents Affected - Few Findings include: Review of Resident #85's medical record revealed an admission date of 07/22/21. Diagnoses included malignant neoplasm of prostate, diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, paraplegia, anemia, hypertension, neurogenic bladder, hyperlipidemia and COVID-19. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had mild cognitive deficit. The resident required extensive assistance of two staff for bed mobility, toilet use and dependent on two staff for transfers. Review of the quarterly restraint/enabler decision tree dated 01/07/22 revealed the resident used one fourth side rails to assist with increased bed mobility, however the enabler (quarter side rails) lacked a physician's order or care plan. Interview on 01/31/22 at 11:27 A.M., with Resident #85 stated he is able to position himself in bed using the side rails but one came off and had asked multiple staff to arrange for the side rail to be replaced on the bed. Observation of the resident's bed at the time of the interview revealed the left quarter side rail was missing. Interview on 01/31/22 at 11:32 A.M., with Licensed Practical Nurse (LPN) #153 verified the bedside rails was missing and the resident was capable of repositioning himself using bilateral side rails. The LPN said it had been reported to the management team on more than one occasion the side rail needed replaced. Interview on 02/02/22 at 4:10 P.M., with Resident #85 revealed the bedside rails had not been replaced despite asking multiple staff. Resident #85 stated he had a history of pressure ulcer to his buttocks and needed to reposition frequently and is unable to without both one fourth side rails on his bed. 366387 Page 3 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to complete documentation and obtain written consent from the resident or resident representative for a change in code status. This affected one (#64) of one resident reviewed for advanced directives. The facility census was 91. Findings include: Review of the medical record for Resident #64 revealed an admission date of [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, dysphagia, hypertension, aphasia, unspecified protein calorie malnutrition, hyperlipidemia, and cognitive communication deficit. Review of Resident #64's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #64's physician's orders revealed an order started on [DATE] and ended on [DATE] for the advance directive of Full Code, further review revealed an order dated [DATE] for the advanced directive of Do Not Resuscitate Comfort Care (DNRCC). Review of the social service note dated [DATE] revealed a care conference was held with Resident #64's family. The facility had discussed the resident's code status with the family and explained each option. The family decided to discuss it further and let the facility know when they had reached a decision. They expressed they wished to keep her comfortable, without any aggressive interventions including Cardiopulmonary Resuscitation (CPR). An additional social service note on [DATE] revealed the resident's family (including the power of attorney) had decided to change Resident #64's code status to DNRCC. The note stated the Certified Nurse Practitioner (CNP) was notified of the change. Review of the progress note created on [DATE] and indicated as effective on [DATE] revealed the nurse spoke to the resident's Power of Attorney regarding the resident's code status. The POA stated he wished for her to be DNRCC. Review of the Certified Nurse Practitioner (CNP)'s progress notes dated [DATE], [DATE], and [DATE], revealed Resident #64's advance directive was full code. Review of the medical record revealed no additional documentation related to Resident #64's code status. Interview on [DATE] at 11:50 A.M., with Social Services Designee #221 revealed Resident #64 and family had wanted to discuss the code status so she gave them the paperwork and allowed them time to discuss it. She reported they later stated they wanted to change her code status to DNRCC but they had not provided the paperwork. She confirmed there was no signed documents confirming the resident and her families wishes to change her code status, but it had been changed in the online medical record. An email from the Administrator on [DATE] at 8:54 A.M., confirmed the medical record did not reflect the new code status in the orders and notes. 366387 Page 4 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0578 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Residents' Rights: Treatment and Advance Directives dated [DATE], revealed upon admission, if the resident had Advance Directives copies should be made and placed in the chart. During the care planing process the facility would identify, clarify and review with the resident or representative whether they desired to make changes to the Advance Directives. Any decision making was to be documented in the resident's medical record and communicated to the interdisciplinary team. Residents Affected - Few 366387 Page 5 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #58 revealed an an initial admission date on 08/01/19 and a readmission date on 05/29/21, with medical diagnoses that included Parkinson's Disease (08/01/19), dementia (08/01/19), bipolar disorder (08/01/19), major depressive disorder (08/01/19), and anxiety disorder (05/29/21). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had impaired cognition on the Brief Interview for Mental Status (BIMS) assessment. Resident #58 required limited assistance from one staff to complete Activities of Daily Living (ADLs) including bed mobility, transfers, and ambulation. There were no behaviors noted in the assessment. Review of the plan of care dated 06/02/21 revealed Pre-admission Screening and Resident Review (PASARR) was not addressed in the resident's plan of care. Review of the PASARR dated 06/01/21 revealed no mental health diagnoses, except dementia, were included on the PASARR. Interview on 02/01/22 at 6:24 P.M., with the Social Services Designee (SSD) #221 confirmed the significant change PASARR dated 06/01/21 did not include any mental health diagnoses, except the dementia diagnosis and did not include the new mental health diagnosis of anxiety disorder that was added on 05/29/21. Based on record review and staff interview, the facility failed to complete a Prea-dmission Screening and Resident Review (PASARR) when for a residnet with a new mental diagnosis and failed to complete accurate PASARR's asseements. This affected three (#32, #58, #69) of three residents reviewed for PASARR's. The facility census was 91. Findings include: 1. Review of the medical record revealed Resident #69 admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, type two diabetes mellitus, chronic kidney disease stage IV, unspecified dementia, major depression, dysphagia, and Parkinson's disease. A diagnoses of unspecified psychosis not due to a substance or known physiological condition was added 03/15/21. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #69's medical record revealed one Preadmission Screening Resident Review (PASARR) was completed on 07/12/19. Interview on 02/01/22 at 11:50 A.M., with Social Services Designee #221 confirmed a PASARR should have been completed when Resident #69 received a new mental diagnoses and it had not been completed. 3. Review of the medical record for the Resident #32 revealed an admission date of 01/15/20, with diagnoses including type two diabetes, hypertension, dementia with behaviors, mild cognitive impairment, unspecified psychosis not due to substance or physiological condition, major depression, history 366387 Page 6 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0644 of COVID-19. Level of Harm - Minimal harm or potential for actual harm Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was rarely or never understood and required extensive assistance of two staff members for bed mobility and transfers. Residents Affected - Few Review of the plan of care dated 12/14/21 revealed Resident #32 had potential for nutrition and hydration alteration with interventions for assistance with meals and provide substitutes and preferences. Care plan revealed resident was at risk for adverse effects of psychoactive medication with interventions provide medications when ordered and assess for behaviors. Review of the progress notes dated 01/04/22 revealed resident was having behaviors. Review of Physician note dated 01/21/22 revealed resident had a diagnosis of psychotic disorder and was ordered medication for this diagnosis. This physician not mentioned changes to residents psychiatric medications. Interview on 02/02/22 at 9:04 A.M., with SSD #221 confirmed resident has dementia with behaviors, unspecified psychosis not due to substance or physiological condition, and major depressive disorder. SSD #221 confirmed the PASARR dated 02/14/20 only had mood disorder major depression listed. SSD #221 verified if she had completed the form, she would have added the psychosis diagnosis to the PASARR. Record review of the PASARR dated 02/02/22 revealed section D Indications of serious mental illness revealed the mood disorder box was checked and described as major depression disorder. 366387 Page 7 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, family and staff interviews, the facility failed to provide individualized activities to meet the needs and interest for one resident. This affected one (#49) of three reviewed for activities. Facility census was 91. Residents Affected - Few Findings include: Review of the medical record for the Resident #49 revealed an admission date of 05/14/21, with diagnoses included cognitive impairments following cerebral infarction, type two diabetes, muscle weakness, lack of coordination, disorder of muscle cognitive communication deficit, aphasia, hyperlipidemia, metabolic encephalopathy, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive impairment and required extensive assistance of two staff members for bed mobility and transfers and extensive one person assist for ambulation, toileting and hygiene. Review of the plan of care dated 11/30/21 revealed Resident #49 had preferences for daily life and person-centered care with interventions to respect choice in activities. The care plan revealed resident did not engage in group activities and prefers doing activities in their room with interventions to watch television and provide room visits, listening to music, religious activities, reading and spending time outdoors. Review of the progress notes dated 10/30/21 revealed resident declined attending the Halloween social. No progress notes were written after 11/01/21 regarding resident attending activities, declining activities, or having activity staff provide visits 1-2 times weekly. Review of Resident activity assessment dated [DATE] and another 01/28/22 revealed resident enjoys playing a variety of card games, watching oldies, sports on television, and enjoyed listening to music, reading war books, practice Christianity, go on shopping trips, sitting and relaying indoors and conversing. The assessment revealed resident prefers activities in his own room and activities staff will visit 1-2 times weekly for social visits. Observation on 01/31/22 at 12:00 P.M., of Resident #49 laying in bed staring at the ceiling in the dark. Resident #49 did not have the television on and room was silent. Observation on 01/31/22 at 12:20 P.M., of State Tested Nurse Assistant (STNA) #186 getting resident up and out of bed and transferred into his wheelchair for lunch. Interview on 01/31/22 at 3:30 P.M., with Resident #49's family revealed no activities are provided to resident, and he is not able to participate himself in many of the facility group activities. She revealed he rarely has staff talk and visit with him and is isolated and lonely in his room. She revealed resident typically was sitting alone in his room watching television when she visited the facility. Observation on 01/31/22 at 4:20 P.M., revealed Resident #49 was sitting in his wheelchair staring off at the wall, television was not on. 366387 Page 8 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 02/01/22 at 8:05 A.M., revealed Resident #49 was laying in bed in the dark with the lights off and was staring at the back wall. Resident was not asleep and television was not turned on, Resident's door was closed and his room was quiet. Observation on 02/01/22 at 8:56 A.M., revealed Resident #49 was sitting in his wheelchair eating breakfast resident was not participating in any in room activities. Observation on 02/01/22 at 12:15 P.M., revealed Resident #49 had gotten up into a chair for lunch and was waiting on his lunch tray. Television was playing but sound was not turned on. Observation on 02/01/22 at 12:25 P.M., revealed Resident #49's food had arrived and he was eating lunch. Resident #49's room was quiet with television sound turned off. Observation on 02/01/22 at 2:54 P.M., revealed Resident #49 was scooting around his room in his wheelchair. Resident #49 appeared restless. Interview on 02/01/22 at 3:28 P.M., with Licensed Practical Nurse (LPN) #159 revealed Resident #49 can participate in activities and would benefit from socialization and having activities to do throughout the day. LPN #159 revealed Resident #49 goes to social hour or happy hour but typically his wife took him to those events. Interview on 02/01/22 at 3:49 P.M. with Resident #49's wife revealed she would like to see him leave the room and socialize with other people as best as he can and should be receiving activities in the room per his preference. Observation 02/02/22 8:40 A.M. revealed resident was sitting in the dark in his wheelchair and was staring at the wall. The television was on and was silent. Interview on 02/02/22 at 11:34 A.M. with Activity Director #102 revealed residents are assessed upon admission and when significant changes occur. Activity Director revealed she completed an activity assessment 11/2021 by talking with Resident #49's wife and confirmed an updated activity assessment was entered 01/2022 but revealed the 01/2022 assessment was copied and pasted from the previous assessment. Activity Director confirmed the activities on the form are not based on residents updated needs, wishes, and abilities. Activities revealed resident activity documentation should be documented in the medial record under progress notes and confirmed no progress notes have been written since 10/30/21. Activity Director provided some hand-written documentation of in room social visits being conducted and confirmed in the last month resident was not met with at least one to two times as per the activity assessment. Observation 02/02/22 at 12:27 P.M. revealed resident slumped over, sleeping in his wheelchair with his lunch tray set up for him and tray table pushed up to him to eat. Resident had the television on with no sound. Observation on 02/02/22 at 1:15 P.M. revealed resident was working on eating breakfast. No in room activities were observed. Review of facility policy titled Activity department policy: Program and scheduling, dated 03/2007, revealed the facility failed to implement the policy in regards to the allegation. The policy revealed the activity department is responsible for planning and scheduling activities diverse in focus 366387 Page 9 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0679 and consistent with resident's wishes and needs. Level of Harm - Minimal harm or potential for actual harm Review of facility activity spreadsheet revealed in 10/2021, Resident #49 attended three activities and was invited to zero additional activities. In 11/2021, resident attended six activities and was invited to eight additional activities. In 12/2021, resident attended two activities and was invited to eight additional activities. In 01/2022, resident attended zero activities and was invited to six additional activities. Residents Affected - Few Review of the activity department social visits log revealed resident was visited three times in 01/2022. No visits were made during the first three weeks of 01/2022. Review of the Activity calendar revealed facility offers four to seven activities each day with social visits scheduled four days per week. 366387 Page 10 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, interviews with staff, a family member and Nurse Practitioner (NP) #263, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement pressuring relieving interventions for a resident at risk for further skin breakdown due to existing pressure ulcers and failed to complete weekly skin assessments. This resulted in Actual Harm when staff failed to implement pressure relieving interventions to prevent further skin breakdown for Resident #49 resulting in the development of an avoidable Deep Tissue Injury (DTI) to the left heel. Resident #49 also had increased measurements in the coccyx and heel pressure ulcers and experienced discomfort during a dressing change. This affected one (#49) of four residents reviewed for pressure ulcers. The facility identified 10 current residents with pressure sores. Facility census was 91. Residents Affected - Few Findings include: Review of the medical record for the Resident #49 revealed an admission date of 05/14/21. Diagnoses included cognitive impairment following cerebral infarction, Type II diabetes, muscle weakness, lack of coordination, disorder of muscle, cognitive communication deficit, aphasia, hyperlipidemia, metabolic encephalopathy, and neuromuscular dysfunction of the bladder. Review of the Braden skin scale (an assessment tool to measure resident risk for developing skin impairments) dated 11/19/21 revealed Resident #49 scored a 14 and was at a moderate risk for developing pressure injuries. Review of the plan of care dated 11/30/21 revealed Resident #49 is at risk for alteration in skin integrity as evidence by pressure ulcer of the right heel with interventions to encourage and assist resident to elevate heels in bed as needed and tolerated, encourage resident to turn and reposition as needed, provide assistance with activities of daily living and positioning as tolerated. The care plan also documented alteration in skin integrity as evidenced by pressure ulcers present to left and right buttock, and according to the focus section of the care plan, since this care plan was written, the two wounds on the buttock have combined to form one on the coccyx, with interventions to assess and complete wound care, encourage resident to turn and reposition as needed, provide assistance with activities of daily living and positioning as tolerated. There is no mention on the care plan of resident having behaviors, refusals of care and non-compliance. No updates have been made to the care plan since the development of the new coccyx wound and new left heel wound. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive impairment and required extensive assistance of two staff members for bed mobility and transfers and required extensive one person assist with ambulation, toileting, and hygiene. The MDS revealed Resident #49 had two unstageable pressure wounds that were facility acquired, one of which presented as a DTI. Resident #49 has a pressure reducing device for his bed, was not involved in a turning or repositioning program, has nutrition and hydration interventions and wound care including ointments and application of dressings. Resident #49 has a urinary catheter and is always incontinent of bowels. Review of Resident #49's physician orders for 05/14/21 identified orders to encourage and assist to turn and reposition as tolerated with instructions to complete every shift. Review of physician orders for 05/18/21 until 02/02/22 identified orders to ensure pressure reduction socks were on 366387 Page 11 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0686 bilateral feet with instructions to complete every shift. Level of Harm - Actual harm Review of Resident #49's physician order from 01/03/22 to 01/10/22 revealed an order for right heel to cleanse with normal saline and apply foam and change daily and as needed. Residents Affected - Few Review of Resident #49's Physician orders from 01/10/22 to 02/01/22 identified orders for right heel cleanse with normal saline apply Calcium Alginate with foam with instructions to change daily and PRN (every night shift and as needed). Review of Resident #49's physician orders for 01/10/22 identified orders for coccyx cleanse with normal saline. Pat dry. Apply Aquacel to wound bed and cover with foam dressing with instructions to complete every night shift and as needed. Review of physician orders for 01/28/22 until 02/12/22 identified orders for flagyl tablet 500 milligrams (mg) with instructions to provide one tablet by mouth three times daily for Coccyx wound infection. Review of Resident #49's physician order for 02/01/22 revealed orders for left heel to cleanse with normal saline and apply cover with ABD and kerlix and change daily and as needed. Review of Resident #49's physician order for 02/01/22 revealed orders for right heel to cleanse with normal saline and apply calcium alginate and cover with ABD and Kerlix and change daily and as needed. Review of Resident #49's physician order for 02/02/22 identified orders to apply bilateral soft cut boots as tolerated. Review of Resident #49's progress notes revealed no mention of resident or family behaviors, refusals, or non-compliance with interventions for pressures reduction. Review of Physician/NP notes dated 01/24/22 revealed Resident #49 presented for wound assessment. The barriers to wound healing include resident cannot self-position, cannot always verbalize needs, and chronic disease state. The medical provider recorded the resident with Stage 3 wound on right heel with wound treatment order. The NP provided education on the importance of offloading and good nutrition to prevent re-injury with the recommendation to continue offloading boots. It is mentioned new and worsening wounds may be unavoidable due to non-compliance with positioning. To note, there is no additional documentation of resident non-compliance and behaviors in the medical record besides what the NP is reported being told. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a left buttock wound with origination date of 11/29/21, described as unstageable with length and width measuring at 0.7 centimeters (cm) x 0.7 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right buttock wound with origination date of 10/08/21, described as unstageable with length and width measuring at 1.5 cm x 0.5 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment. Review of skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with 366387 Page 12 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0686 Level of Harm - Actual harm Residents Affected - Few origination date of 11/29/21 described as unstageable with length and width measuring at 3.5 x 3.5 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment with note left buttock and right buttock have connected making one pressure area to coccyx. Review of skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 8.0 cm x 4.5 cm with serosanguineous drainage and was noted to have declined from the previous assessment with note to continue current treatment. There was no skin grid assessment available for the week of 01/17/22. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 8.0 cm x 4.5 cm with serosanguineous drainage and was noted to have declined from the previous assessment with note to continue orders. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 3.0 cm x 4.2 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment with note to continue current treatment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as Stage II with length and width measuring at 0.3 cm x 0.5 cm with scant serosanguineous drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length and width measuring at 3.0 cm x 3.5 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width and depth measuring at 2.5 cm x 4.0 cm x 0.1 cm with no drainage and was noted to be improved from the previous assessment. There was no skin grid assessment available for the week of 01/17/22. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width and depth measuring at 2.0 cm x 4 cm x 0.1 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width, and depth measuring at 1.0 cm x 3.0 cm x 0.2 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a new left heel wound with origination date of 02/01/22 described as a DTI with length and width measuring at 5.0 cm x 2.5 cm with no drainage with note for 100% intact blister noted. Review of the Behavior tasks tracking revealed Resident #49 had no documented behaviors daily from 01/06/22 to 02/03/22, except on 01/25/22, when the resident was documented to have repeated 366387 Page 13 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0686 movements and was comforted and redirected. Level of Harm - Actual harm Review of the Ulcer/Injury unavoidability checklist dated 07/29/21, 11/29/21 and 02/01/22 revealed a Registered Nurse (RN) and Licensed Practical Nurse (LPN) signed the form with e-signatures. The checklist marks the implemented interventions that were consistent with residents needs and goals and included turning and repositioning as needed or resident turning themselves independently or the pressure ulcer is not related to turning. Residents Affected - Few Review of the facility provided timeline of the wound revealed on 01/31/22, Resident #49 and spouse revealed the resident would not wear the offloading boots due to being too bulky and new boots were given to the resident. Resident #49 continues to refuse, and spouse is known to remove the boots after staff place them on resident. There was no mention of any of these events documented in progress notes or the behavior section of the resident's electronic medical record. Observation on 01/31/22 at 12:00 P.M., revealed Resident #49 lying in bed flat on his back looking up at the ceiling. Resident #49 did not have any pillows in bed for repositioning and offloading of his coccyx or heel wounds. Interview on 01/31/22 at 3:30 P.M., with Resident #49's family member revealed concerns related to the resident's wounds. Resident 49's family member revealed he has a new wound on his left heel, that the family member informed staff about, and expressed concerns the resident is not turned and repositioned throughout the day. Observation on 01/31/22 at 4:20 P.M., revealed Resident #49 sitting in his wheelchair and wearing gray non-slip socks. Resident #49 was observed to be holding his feet up off the ground. Observations on 02/01/22 at 8:05 A.M., revealed Resident #49 was lying in bed flat on his back with no pillow or devices for offloading the heals. Resident #49 had blue pressure relieving boots sitting on a chair in his room. Observation on 02/01/22 at 8:56 A.M., revealed Resident #49 was sitting in his wheelchair, he did not have the wheelchair foot rests on his chair or the blue pressure relieving boots on his feet, but did have non-slip socks on both feet. Observation on 02/01/22 at 12:25 P.M., revealed Resident #49 remained in his wheelchair and was eating lunch. Resident #49 did not have blue pressure relieving boots on and was wearing non-slip socks. Observation on 02/01/22 at 1:55 P.M., revealed LPN #151, LPN #159, and Assistant Director of Nursing (ADON) #109 entered Resident #49's room and washed their hands. LPN #151 cleansed the resident's bedside table with a bleach wipe and allowed to dry. LPN #159 pulled the resident's blankets back and the resident was noted to have one gray non-skid sock on the right foot with red drainage to the sock. Resident #49 had no heel protectors in place. Pillows were placed under the resident's calves; however, the resident's heels were observed to be pressing into the resident's bed. Resident #49 was positioned on his back with no offloading of the coccyx or his heels. Resident #49 was placed on his right side by LPN #159. LPN #151 removed the soiled dressing dated 02/01/22. ADON #109 measured the coccyx wound at 3.0 cm by 5.0 cm by 0.2 cm with 50% slough with a pinkish-red wound bed. ADON #109 sanitized her hands, donned gloves, and cleansed the coccyx wound with normal saline (NS) and four by four gauze. ADON #109 sanitized her hands, donned gloves and applied calcium alginate and covered 366387 Page 14 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0686 Level of Harm - Actual harm Residents Affected - Few with a foam dressing. The nurses washed their hands and donned gloves, LPN #151 attempted to remove the non-skid sock from his right foot, however the sock was stuck to the wound to his heel. LPN #151 soaked the sock off the wound using normal saline (NS). Resident #49 was observed moaning out in pain while LPN #151 removed the sock from the wound. ADON #109 cleansed the wound with NS and four by four gauze, sanitized her hands, covered the wound with calcium alginate, padded with ABD pad and secured with Kerlex wrap and tape. Resident #49 was also noted to have a DTI to his left heel measuring 5.0 cm by 2.5 cm with a 100% intact blister. ADON #109 padded the left heel with an ABD pad, wrapped with Kerlex and secured with tape. ADON #109 verified the facility was unaware of the newly developed DTI to his left heel, the heels not being elevated and the lack of off-loading to his coccyx. Observation on 02/01/22 at 2:54 P.M., of Resident #49's room revealed a black wheelchair footrest on the couch and had light blue padded booties also sitting on the couch. Interview on 02/01/22 at 3:28 P.M. with LPN #159 revealed Resident #49 has wounds on his coccyx and right heel and a newly found left heel wound. LPN #159 revealed facility is looking at getting an air mattress and revealed Resident #49's family puts pillows under the resident's legs. LPN #159 revealed Resident #49 had large green boots, but the resident and his family did not like them due to being too big. LPN #159 confirmed Resident #49 does not have pillows, or a device used to off load pressure from his coccyx or his heels. Interview on 02/01/22 at 3:49 P.M. with Resident #49's family revealed she has never seen the resident wear the blue pressure relieving boots sitting on the chair and revealed she has never actually seen them in his room before. Observation on 02/01/22 at 3:49 P.M., revealed Resident #49 was lying in bed with pillows under his feet with wound bandages on both heels and his feet were without any covering such as socks or pressure relieving boots. Resident #49 was lying flat on his back with no devices or interventions for coccyx offloading. Observation on 02/02/22 at 8:40 A.M., revealed Resident #49 was sitting in his wheelchair with non-slip socks on and holding his feet up off the ground. Observation on 02/02/22 at 12:27 P.M., revealed Resident #49 sleeping in his wheelchair. Resident #49 was wearing non-slip socks and his blue pressure relieving boots were sitting on the chair in the resident's room. Interview on 02/02/22 at 1:20 P.M., with Director of Nursing (DON) #130 and Corporate RN #107 revealed Resident #49 had orders for the blue relieving boots to be worn only at nighttime, which was why he has not worn them during any observations. DON #130 and Corporate RN #107 confirmed during interview and observation, the blue medial boots were sitting on Resident #49's chair and were not being worn. DON #103 and Corporate RN #107 stated Resident #49 is non-complaint with interventions but could not provide further information why offloading was not being used for his wounds and could not provide examples of Resident #49's non-compliance. DON #130 and Corporate RN #107 revealed Resident #49 has pillows available for offloading and pointed to a closet (when asked where they were). DON #130 and Corporate RN #107 were unable to explain why the pillows have not been used during any observations for off-loading of his coccyx wounds or heels. Interview on 02/02/22 at 4:00 P.M., with Corporate RN #107 revealed the physician order for compression socks to bilateral feet to be worn during each shift should be assumed to be the blue pressure 366387 Page 15 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0686 relieving boots, and confirmed no actual order is present for the boots. Level of Harm - Actual harm Interview on 02/03/22 at 3:50 P.M., with the facility NP #263 revealed the previous facility NP recently resigned from her position and NP #263 is filling in for the interim. NP #263 revealed her expectations for a resident with confusion would be for staff to check on resident every two hours and staff should be providing offloading support for wound healing. NP #263 revealed a pressure reducing sock is a type of medical device and confirmed it is different than the pressure relieving boots that were present in Resident #49's room. NP #263 revealed the typical treatment for heel pressure wounds would be for resident to wear off loading boots each shift. NP #263 revealed if a resident was resistant to care, showing signs of aggression, or signs of non-compliance, she would expect this to be clearly documented in the medical record. NP #264 confirmed at times staff will tell the NP's or physician about a resident's behaviors during visits, and this may be documented in their record but was not necessarily first-hand knowledge. NP #263 revealed Resident #49 was assessed on Monday for wound care and denied seeing any aggressive behavior or compliance concerns during this visit. Residents Affected - Few Review of information from the NPUAP revealed an unstageable pressure injury is a full thickness skin and tissue loss and the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead dry harden tissue). If slough or eschar is removed a stage three of stage four is revealed. This injury results from intense and or prolonged pressure and shear force at the bone-muscle interface. A DTI is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The NPUAP indicated to use a structured risk assessment such as the Braden scale to identify individuals at risk for pressure injury as soon as possible (but within eight hours of admission) and based on the identified risk factors a care plan should be developed and implemented. Further review of the NPUAP revealed the facility should assess pressure points, such as the buttocks, heels, ischium, trochanter's elbow, and beneath medical devices. The NPUAP also indicated that the heels are free from the bed and use of heel offloading devices or polyurethane foam dressing on individuals at risk for heel ulcers. 366387 Page 16 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and family interviews, the facility failed to encourage fluids per physician orders, monitor oral intake of fluids, and obtain weights according to physician orders. This affected one (#49) of eight residents reviewed for nutrition and hydration. Facility census was 91. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #49 revealed an admission date of 05/14/21. Diagnoses included cognitive impairments following cerebral infarction, type two diabetes, muscle weakness, lack of coordination, disorder of muscle cognitive communication deficit, aphasia, hyperlipidemia, metabolic encephalopathy, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive deficit and required extensive assistance of two staff members for bed mobility and transfers and extensive one person assist ambulation, toileting and hygiene. a. Review of physician orders for 11/26/21 identified orders for encourage fluid intake resident does not like water, with instructions four times daily. Review of medical record revealed Resident has had recurrent urinary tract infection (UTI)'s in 11/2021, 12/2021, 01/2022, and is actively prescribed antibiotics for a UTI as of 02/2022. Observation on 01/31/22 at 12:00 P.M., of Resident #49 laying in bed. Resident's bed side tray table was across the room at least 6 feet from his reach with a tan pitcher for fluids sitting on it. Observation on 01/31/22 at 12:20 P.M., of State Tested Nurse Assistant (STNA) #186 getting resident up and out of bed and transferred into his wheelchair for lunch. STNA #186 moved resident's bed side tray table and positioned it in front of resident in his wheelchair for easy reach and brought resident his lunch tray. Resident's lunch tray had 2 milks, no juice and no water. STNA #186 encouraged resident to eat lunch since he did not eat or drink anything for breakfast. Interview on 01/31/22 at 3:30 P.M., with Resident #49's family revealed concerns about resident's fluid intake. She revealed the resident is given a pitcher of water that he is not able to lift and the straw does not stick out enough at the top for him to be able to use it easily. She also revealed the resident does not like the taste of water and reported staff have been asked to mix in some juice for flavoring and it was requested resident get an extra milk with meals. Observation on 01/31/22 at 4:20 P.M., revealed Resident #49 was sitting in his wheelchair with his tray table within reach and his water pitcher within reach. The straw only come out the top of the pitcher about one inch. The pitcher did not have any fluid in it during this observation. Observations on 02/01/22 at 8:05 A.M., revealed Resident #49 was lying in bed in the dark with his tray table pushed up against the wall and out of reach of the resident. Resident's water pitcher was on tray table and also out of reach. Observation on 02/01/22 at 8:56 A.M., revealed Resident #49 was sitting in his wheelchair eating breakfast and had two milks. 366387 Page 17 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/01/22 at 1:50 P.M., with Resident #49's family revealed she had requested the facility on multiple occasions to replace the resident's water pitcher due to the pitcher being too heavy and the straw not being long enough for him to drink out of. Assistant Director of Nursing (ADON) #109 acknowledge she would obtain a handled cup from the kitchen for the resident to use that he could handle. The resident's wife also requested a small amount of juice she supplied to be placed in the resident's water to flavor the water so he would consume it. ADON #109 verified she would ensure the request was honored. Observation on 02/01/22 2:54 P.M., revealed Resident #49 was sitting in his wheelchair and had his tray table and pitcher within reach. Resident #49's pitcher did not have any fluids in it. Interview on 02/01/22 at 3:28 P.M., with Licensed Practical Nurse (LPN) #159 revealed Resident #49 was supposed to get fluids constantly. LPN #159 revealed the aides do not give him enough water to drink and typically only give him drinks with meals. LPN #159 revealed the resident does not like water and his family requested some juice be added for flavoring to get him to drink more. Interview on 02/01/22 at 3:33 P.M., with Dietician #126 revealed she has worked with Resident #49 since admission. Dietician #126 revealed she will monitor fluid and nutrition intakes. Observation on 02/02/22 at 8:40 A.M., revealed Resident #49 was sitting in the dark in his wheelchair. Resident was sitting near his bedside table where the pitcher was located. The pitcher did not have any fluid in it. Observation on 02/02/22 at 12:27 P.M., revealed Resident #49 sleeping in wheelchair with his lunch tray in front of him with 2 milks. The pitcher did not have fluid in it. This was verified with Dietician #126. After surveyor intervention the Dietician #126 informed the bedside aide to refilled resident's cup with fluids. Review of the nutrition intake logs from the last 60 days reveled fluid intakes were not correctly monitored and documented on 12/02/21, 12/05/21, 12/06/21, 12/09/21, 12/10/21, 12/11/21, 12/12/21, 12/13/21, 12/14/21, 12/15/21, 12/16/21, 12/17/21, 12/18/21, 12/20/21, 12/21/21, 12/26/21, 12/27/21, 12/30/21, 12/31/21, 01/01/22, 01/03/22, 01/04/22, 01/05/22, 01/08/22, 01/09/22, 01/10/22, 01/12/22, 01/14/22, 01/16/22, 01/17/22, 01/18/22, 01/19/22, 01/20/22, 01/21/22, 01/22/22, 01/23/22, 01/26/22, 01/29/22, 01/30/22, and 01/31/22. Staff incorrectly put their initials instead of fluid amounts and left many meals blank without any measurement of fluid amounts listed. The highest amount documented was 700 milliliters (ml) with most meals documented at 240 ml. Interview on 02/03/22 at 9:10 A.M., with Dietician #126 revealed with resident's weight he should be consuming 33-35 ml per kilogram which equaled 2285 ml to 2660 ml per day. Dietician #126 revealed she monitors the intake logs and if she notices staff not entering the amount, she will monitor the resident to see his intake amounts. Dietician #126 revealed she was aware of many missing documentation for fluid intake. b. Review of physician orders for 08/25/21 through 12/03/21 revealed resident had orders for weekly weights. Review of the Care plan dated 10/08/21 revealed residents was at risk for nutrition and hydration concerns with intervention to obtain weights are ordered. 366387 Page 18 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0692 Review of the progress notes from 08/25/21 to 10/06/21 with no mention of weight refusals or behaviors. Level of Harm - Minimal harm or potential for actual harm Review of the weight logs revealed on 08/25/21 residents weight was 198.7 lbs. No weight was entered from 08/25/21 until 10/06/21 when residents weight was 168.5 lbs. Resident had a 30.2 lbs weight loss in 6 weeks for 15.2% weight loss. Residents Affected - Few Interview on 01/31/22 at 3:30 P.M. with Resident #49's family revealed concerns regarding resident weight loss in the past few months. She reported it had stabilized with nutritional supplements and encouragement to eat. Interview on 02/01/22 at 3:28 P.M. with LPN #159 revealed resident can participate in activities and would benefit from socialization and having activities to do throughout the day. LPN #159 revealed resident goes to social hour or happy hour but typically his wife took him to those events. Interview on 02/03/22 at 9:10 A.M., with Dietician #126 revealed she asks for weights daily and if not completed put them on a weekly form to alert staff to the need for a weight. Dietician #126 revealed she had requested staff to obtain resident's weights several times and if he did not need staff assist, would have gotten the weight herself. Dietician #126 revealed resident was pretty easy going and was not known for refusing weights and was not sure why his weighs were not completed as ordered. 366387 Page 19 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record and staff interview, the facility failed to implement pharmacy recommendations. This affected one (#69) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of the medical record revealed Resident #69 admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, type two diabetes mellitus, chronic kidney disease stage IV, unspecified dementia, major depression, dysphagia, unspecified psychosis and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. Review of the Resident #69's physician's orders revealed an order dated 06/07/21 to 02/02/22 for Seroquel 25 mg one tablet at bedtime and Seroquel 50 mg at bedtime. Review of the pharmacy recommendations for Resident #69 dated 04/08/21 and 07/07/21, revealed the pharmacist recommended the facility perform an Abnormal Involuntary Movement Scale (AIMS) assessment at that time and every six months after, due to the resident being on Seroquel. The physician agreed to the recommendations on 05/04/21 and 07/16/21 respectively. Review of Resident #69's assessments, revealed an AIMS assessment was started on 06/25/21 and completed 07/08/21. Review of the medical record from 04/08/21 to 01/31/22 revealed no further AIMS assessments. Interview on 02/02/22 at 2:36 P.M., with Registered Nurse #260 confirmed the physician agreed to the recommendation to complete an AIMS assessment at the time of the recommendation and every six months after. She was unable to provide evidence this was completed. 366387 Page 20 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of policy, the facility failed to hold blood pressure medication when a resident's blood pressure was outside of the parameters (Resident #88). The facility also failed to monitor edema while on a diuretic medication and monitor bruising while on an anticoagulant medication for a resident (Resident #37). The deficient practices affected two (Residents #37 and #88) of six residents reviewed for unnecessary medications. The facility census was 91. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #88 revealed an admission date on 07/13/21, with medical diagnoses included arteriosclerotic heart disease, venous insufficiency, paroxysmal atrial fibrillation, personal history of transient ischemic attack (TIA) and cerebral infarction (stroke), essential primary hypertension (high blood pressure), and presence of automatic cardiac defibrillator. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was rarely or never understood. According to the staff assessment, Resident #88 had moderately impaired cognition. The resident required extensive assistance from one staff person to complete Activities of Daily Living (ADLs). Review of the current February 2022 physician's orders revealed Resident #88 had an order for Carvedilol Tablet 12.5 milligrams (mg) with instructions to give one tablet by mouth two times a day for hypertension and to hold the medication for a systolic blood pressure (the first number) less than 120 and to call the physician if it was less than 100. The order had a start date of 07/13/21. Review of the Medication Administration Record (MAR) for November 2021 revealed Resident #88 had the following blood pressure (BP) readings: 11/04/21 the bedtime BP was 119/67, 11/07/21 the bedtime BP was 90/53, 11/09/21 the bedtime BP was 119/73, 11/18/21 the bedtime BP was 119/87, 11/25/21 the bedtime BP was 105/69, and 11/29/21 the bedtime BP was 84/42. The Carvedilol medication was still administered to Resident #88 on 11/04/21, 11/09/21, 11/18/21, and 11/25/21. The medication was held on 11/07/21 and 11/29/21. Review of the MAR for December 2021 revealed Resident #88 had BP readings of 118/72 in the morning and 118/67 at bedtime and the Carvedilol medication was still administered to the resident. Review of the MAR for January 2022 revealed Resident #88's BP readings were not documented. Carvedilol medication was administered two times a day except at bedtime on 01/11/22, in the morning on 01/12/22, at bedtime on 01/14/22, and in the morning on 01/24/22. The medication was administered at bedtime on 01/24/22. Review of the Blood Pressure Summary dated from 11/01/21 through current revealed Resident #88's blood pressure (BP) was documented on 01/24/22 and 01/25/22 only. Resident #88 had a BP of 114/56 at 8:45 A.M. and 118/62 at 4:23 P.M. on 01/24/22. No other BP readings were documented for the month of January. Review of the nurse's notes dated from 11/01/21 through current revealed there was no evidence the physician had been notified of Resident #88's BP readings of 90/53 on 11/07/21 or 84/42 on 11/29/21. 366387 Page 21 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/02/22 at 12:46 P.M., with the Director of Nursing (DON) confirmed Resident #88 was administered Carvedilol on the above dates when the resident's BP was outside of the provided parameters. The DON also confirmed there was no evidence the physician was notified when Resident #88's systolic BP was less than 100 as indicated on the physician's order. The DON also confirmed there were no documented BP readings on the MAR for the month of January and confirmed the resident's BP was only documented on 01/24/22 and 01/25/22 under the resident's vitals in his electronic medical record. Additional evidence that Resident #88's BP was monitored for January 2022 was requested but none was provided during the survey period. Review of the facility policy, Medication Administration, dated 06/21/17, stated, Medications will be administered by legally authorized and trained persons in accordance to applicable State, Local, and Federal laws and consistent with accepted standards of practice. Furthermore, the policy also stated, Read the label comparing to the MAR before preparing the medication. The facility should follow any specific regulatory requirements in regard to medication administration and obtain and record any vital signs as necessary prior to medication administration. 2. Review of the medical record for Resident #37 revealed an admission date of 04/30/21, with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, type two diabetes mellitus, unspecified diastolic heart failure, arteriosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, major depressive disorder, unspecified dementia without behavioral disturbance, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. The resident received an anticoagulant and diuretic for seven days during look back period. a. Review of Resident #37's physician's orders revealed an order dated 08/12/21 to 01/31/22 and 01/31/22 to current for Torsemide Tablet 20 milligrams (mg) one time a day for chronic heart failure and edema. Additional review revealed order dated 02/01/22 (to start 02/02/22) for Torsemide 10 mg in the morning was ordered for three days for fluid retention. Review of Resident #37's January and February Medication Administration Record (MAR) revealed the Torsemide was provided as ordered. Review of the medical record from 01/01/22 to 02/02/22 revealed no documentation related to Resident #37's edema. Observation on 01/31/22 at 10:52 A.M. and 02/01/22 at 4:35 P.M., of Resident #37 revealed the resident had edema in her bilateral feet, her right ankle was edemic as well. Interview on 01/31/22 at 10:52 A.M., with Resident #37 revealed her edema began on Friday. Interview on 02/01/22 at 4:31 P.M., with Licensed Practical Nurse (LPN) #162 revealed when a resident presents with new edema a progress note should be made indicating if the resident had pain, pitting, what interventions were put in place, and physician notification. LPN #162 confirmed Resident #37 had edema in her lower extremities, unsure how long this had been going on, she learned of it from the resident that morning. Interview on 02/01/22 at 4:36 P.M., with LPN #151 confirmed she had worked with Resident #37 on 366387 Page 22 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 01/31/22. She confirmed the resident had edema on that day. She reported she was unsure how long the resident had edema as it had been passed on to her from the night shift. LPN #151 revealed she knew what the pitting for the residents edema was but had not documented it. Interview on 02/02/22 at 4:11 P.M. with the Director of Nursing (DON) revealed she was aware Resident #37 had edema. The DON revealed she did not know how long the resident presented with edema. The DON was asked to provide documentation related to the residents edema, no additional documents were provided. b. Observation on 01/31/22 at 10:48 A.M. of Resident #37 revealed she had a large bruise on her left upper arm and two small bruises on her right hand. Review of the Resident #37's physician's orders revealed an order dated 08/18/21 for Eliquis Tablet 5 milligrams (mg) two times a day for paroxysmal atrial fibrillation. Review of Resident #37's January and February MAR's revealed the Eliquis was provided as ordered. Review of Resident #37's plan of care dated 05/18/21 revealed the resident was at risk for bleeding, bruising, and abnormal labs related to the use of anticoagulant or thrombolytic medications. Interventions included administering first aide as needed to stop bleeding, administering medications as ordered, monitoring for adverse side effects including increased bleeding, development of bruising hematomas, new clot formation, increased heart rate, and lower extremity edema. Observation on 02/02/22 at 1:20 A.M., of Resident #37 with LPN #161 confirmed the resident had a large bruise to her left upper arm, two small bruises to her right hand, and at that time it was noted she had several bruises across her abdomen. Interview on 02/02/22 at 1:20 P.M., with Resident #37 revealed she was not sure where the bruises had come from. Interview on 02/02/22 at 1:20 P.M., with LPN #161 revealed she was unaware of the bruises. She reported she had been in to see the resident to do her foot treatment earlier that day. LPN #161 did not know who should report on bruises, she thought it should have been done by the wound nurse. Interview on 02/02/22 at 1:35 P.M. and 4:11 P.M., with the Director of Nursing (DON) revealed residents on anticoagulants should be monitored for unusual bruises and bleeding. She reported normally these bruises would be monitored and documented for three days and reported to the physician. The DON was unsure if the facility should have been monitoring Resident #37's bruising or not. She reported that given the location of the bruising on her arm and abdomen it was likely from insulin. 366387 Page 23 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure medication were not left on resident's bedside and failed to ensure resident did not have medications that was not prescribed to her by the physician in her room. This affected two (#4 and #6) of five residents review medication. The facility census was 91. Findings include: 1. Record review of Resident #4 revealed an admission date of 07/26/21, with diagnoses including: cerebral infarction due to occlusion of right anterior cerebral artery, atrial fibrillation, osteoarthritis right knee, dysphagia, muscle weakness, need for assistance with personal care, aphasia, apraxia, protein calorie malnutrition, vitamin D deficiency, insomnia, and hypertension. Review of the quarterly minimum data set (MDS) dated [DATE] revealed the resident is rarely never understood, need assistance with personal hygiene, toilet use, dressing, bed mobility. Obervations on 01/31/22 at 12:09 P.M., revealed in Resident #4's room revealed a medicine cup and in it three unknown pills siting on resident's bedside table. Interview on 01/31/22 at 12:13 P.M., with License Practical Nurse (LPN) #114 confirmed the three pills in the medicine cup left on Resident #4's bedside table should not be there. Interview on 01/31/22 at 12:15 P.M., Registered Nurse (RN) #214 confirmed he left the medication at the Resident #4's bedside table. He said he got distracted when he was pulled out of the resident's room during medication administration to call the physician. He revealed he forgot to take the pills with him when leaving the room. He confirmed the medication to be Calcium Citrate 200 milligram (mg) tablet, Fibercon 625 mg table, and Vitamin C. 2. Record review for Resident #6 revealed an admission date of 10/05/21, with diagnoses including chronic atrial fibrillation, muscle weakness, dyspnea, major depressive disorder, presence of right artificial shoulder joint, and anemia. Review of the quarterly MDS assessment, dated 01/12/22, revealed this resident had moderately cognitively impaired evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require one person assist with personal hygiene, toilet use, dressing, bed mobility Review of the physician's orders, dated 10/06/21, revealed resident had an order for icy hot patch 5 percent menthol, apply to right knee topically one time a day for arthritis pain. Review of the care plan, dated 10/19/21, revealed resident had altered health maintenance related to physical and mental status due to diagnosis fracture of the shaft of humerus refectory, anemia, chronic atrial fibrillation, dyspnea, and major depressive disorder paroxysmal. Interventions included administer medication as ordered, monitor for signs and symptoms of cardiac distress and report. During medication administration on 02/02/22 at 8:58 A.M. with Assistant Director of Nursing (ADON) 366387 Page 24 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0761 Level of Harm - Minimal harm or potential for actual harm LPN #109 revealed Resident #6 icy hot patch was not in the medication cart. LPN #109 proceeded to look for the resident's patch in her drawer in her room. Upon opening the drawer, observed muscle rub patched that wasn't that was not prescribed for the resident in the drawer including Centrum silver, ketoconazole cream 2 percent (%), and ciclopirix topical nail lacquer inside the drawer. Also observed elderberry gummies supplement in a bottle sitting on a table in the resident's room. Residents Affected - Few Review of the physician's orders and MAR for the month February 2022, revealed resident was not ordered centrum silver, ketoconazole cream 2 percent, cicloprix topical nail lacquer, muscle rub patched, and elderberry supplement. Interview on 02/02/22 at 8:58 A.M., with LPN #109 confirmed medication found in Resident #6's room was not ordered for the resident and should not be in her room. She revealed the resident's son bring the medication to the resident. Review of the policy titled Medication Administration dated 06/21/17, revealed administer medication and remain with resident while medication is swallowed. Never leave a medication in a resident's room without orders to do so. 366387 Page 25 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to keep an accurate medical record, when the nurse signed off on a skin assessment prior to completing it. This affected one (#37) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of the medical record for Resident #37 revealed an admission date of 04/30/21, with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, type two diabetes mellitus, unspecified diastolic heart failure, arteriosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, major depressive disorder, unspecified dementia without behavioral disturbance, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. The resident received an anticoagulant and diuretic for seven days during look back period. On 02/02/22 at 1:16 P.M., review of the February 2022 TAR revealed the weekly head to toe skin check was marked as completed by the nurse. Interview on 02/02/22 at 1:20 P.M., with Licensed Practical Nurse (LPN) #161 revealed she had not completed the weekly skin check but had marked it as complete on the TARS. LPN #161 stated she would do it after dinner so the resident would be completely naked for the assessment. 366387 Page 26 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #43 revealed an admission date of 12/04/21, with diagnoses including: Alzheimer's disease, dementia, arteriosclerotic heart disease of coronary artery, B group vitamin deficiency, major depressive disorder, hyperlipidemia, anxiety disorder, vitamin D deficiency, asthma, cardiac arrhythmia, cognitive communication deficit, and iron deficiency anemia. Residents Affected - Some Review of the 12/11/21, admission Minimum Data Set (MDS) assessment revealed the Resident #43 is moderately cognitively impaired and requires limited assistance for bed mobility, transfer, toilet use, and is independent in his other activities of daily living. The Resident uses a walker and wheelchair to aid in mobility and is always continent of bowel and bladder. Review of physician's order dated 12/05/21 revealed an order for Cyanocobalamin Tablet (Vitamin B-12) 1000 Micrograms give one tablet by mouth one time a day every Mon, Wed, Fri for vitamin deficiency. Review of physicians order dated 12/06/21 revealed an order for Ferrous Sulfate Tablet 325 (65 iron) milligram give one tablet by mouth two times a day for iron and an order for Vitamin D 3 Capsule 125 microgram (5000 units) (Cholecalciferol), give one capsule by mouth one time a day for vitamin deficiency. Observation on 02/02/22 at 8:12 A.M., revealed Licensed Practical Nurse (LPN) #161 passing medications for Resident #43. LPN #161 took out a pill bottle with vitamin B-12 500 micrograms and shook out two tabs into her hand and placed them in the medicine cup. LPN #161 then took out a bottle of ferrous sulfate 325 milligrams and shook out one pill in her hand and then placed it into the medicine cup. The Nurse took out the bottle of vitamin D-3 50 micrograms and shook out three tablets into her hand placed two in the medicine cup and dropped one on the carpet. LPN #161 picked up the pill off the carpeted floor and threw it away and then took out another D-3 tablet and placed it in her hand and then in the medicine cup. LPN #161 did not wash her hands after touching the pills or the carpet. LPN #161 then reached her fingers into the medicine cup and pulled out pills and split them using a pill splitter. Interview with LPN #161 on 02/02/22 at 8:28 A.M., verified she touched the medicine with her bare hands and did not wash her hands after picking up a pill off the floor and touched other medications. Review of a policy titled Medication Administration policy dated 06/21/17 revealed to cleanse hands as appropriate and for tablets and capsules never touch any of the medications with fingers. Based on observation, record review, staff interviews, review of Center for Disease Control and Prevention (CDC) guidleines, facility policy review, the facility failed to maintain infection control practices to prevent the spread of COVID-19. This had the potential to affect all residents except the eight COVID-19 positive residents (#5, #17, #20, #23, #44, #85, #90 and #394). Additionally, the facility failed to maintain acceptable infection control practices when handling medications. This deficient practice affected one (#43) of five residents reviewed for medication administration. The facility census was 91. Findings include: 1. Observations on 01/31/22 at 12:13 P.M., of Housekeeper #131 enter the COVID-19 unit without a 366387 Page 27 of 28 366387 02/11/2022 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0880 Level of Harm - Minimal harm or potential for actual harm gown or gloves. The Housekeeper #131 said she was not required to wear a gown or gloves on the COVID-19 unit. Additional observations of the Housekeeper #131 revealed she then exited the COVID-19 unit onto a non COVID-19 unit without changing her mask (N95 or surgical mask), or cleansing her eye protection (goggles or face shield). Housekeeper #131 verified the lack of gown, gloves, changing of masks and cleansing of overprotection at the time of the observation. Residents Affected - Some 2. Observstion on 02/01/22 at 3:25 P.M., of Non-Certified Nursing Assistant (NCNA) #175 retrieved a bag of disposable briefs from a supply closet located on the COVID-19 unit and handed the bag of disposable briefs through a gap in the barrier wall to an unidentified aide on a non COVID-19 unit. The NCNA verified she provides the non COVID-19 hallways with the incontinence briefs when requested. 3. Observation on 02/01/22 at 4:20 P.M., of NCNA #175 revealed she removed her reusable gown, donned her coat, exited the COVID-19 unit onto a non COVID-19 unit with a black trash can full of trash. The NCNA was observed leaving the unit without cleansing her eye protection taking the trash through the non COVID-19 units to disposable receptacle. The NCNA verified the trash and laundry from the COVID-19 unit are taken through non COVID-19 units to the laundry area and the dumpster. Review of the CDC guidelines Sparkling Surfaces: Stop COVID-19's Spread revealed the virus that causes COVID-19 can be spread by indirect contact with contaminated surfaces. Surfaces that were touched frequently increase the chance that germs could be spread to residents and staff. On surfaces which look clean, pathogens might be present. The coronavirus causing COVID-19 has been shown to survive on surfaces from several hours to days. Review of the facility policy titled, Novel Coronavirus Prevention and Response, dated 04/09/20 revealed, the facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat and prevent the spread of the virus. Housekeeping staff shall adhere to transmission-based precautions. 366387 Page 28 of 28