Health inspection·September 25, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review the facility failed to ensure care conferences were provided quarterly for the residents. This affected three (#6, #20, and #42) of three residents reviewed for care conferences. The facility census was 97. Findings included: 1. Medical record review for Resident #6 revealed an admission date to the facility on [DATE]. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of a progress note dated 05/09/23 revealed Resident #6 and the family were offered a care conference. Review the progress notes from 08/01/23 through 09/24/23 revealed there was not any evidence a care conference was offered to the resident and family. Interview with Resident #6 on 09/25/23 at 10:37 A.M. revealed she had not received a care conference since she had been a resident at the facility. Interview with the Director of Nursing (DON) on 09/25/23 at 9:43 A.M. revealed Resident #6 and family were offered a care conference on 05/09/23. The DON confirmed there was not a care conference held for Resident #6 since 05/09/23. 2. Medical record review for Resident #20 revealed an admission date of 12/08/20. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. Further review of Resident #20's medical record 09/15/22 to 09/24/23 revealed there was not any evidence of care conferences since 09/15/22. Interview with the Director of Nursing (DON) on 09/25/23 at 9:43 A.M. confirmed Residents #20 did not have evidence a care conference held this year from 01/01/23 to 09/24/23. The DON confirmed the last conference for Resident #20 was on 09/15/22. 3. Medical record review for Resident #42 revealed an admission date of 05/10/17. Diagnoses included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. Page 1 of 3 366387 366387 09/25/2023 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #42's medical record 09/15/22 to 09/24/23 revealed there was not any evidence of care conferences since 12/30/22. Interview with the Director of Nursing (DON) on 09/25/23 at 9:43 A.M. confirmed Residents #42 did not have evidence a care conference held this year from 01/01/23 to 09/24/23. The DON confirmed the last conference for Resident #42 was on 12/30/22. Review of the facility policy titled Resident/Resident Representative Care Conference, dated 08/08/06, revealed the purpose was to provide the resident and/or resident representative the opportunity to participate in the resident's plan of care. On admission, the resident and/or resident representative will be informed of the facility's care conference protocols. They will be offered an initial care conference meeting. They will also be informed of a projected schedule for quarterly care conferences for the year, and that they may request a care conference at any time. This deficiency represents non-compliance investigated under Complaint Number OH00146155. 366387 Page 2 of 3 366387 09/25/2023 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to ensure a resident, who was incontinent of bowel and bladder and dependent on staff for toileting, received the appropriate treatment and services for incontinence care. This affected one (#42) of three residents reviewed for incontinence care. The facility identified there were 22 residents who were incontinent of bowel and/or bladder. The facility census was 97. Findings include: Medical record review for Resident #42 revealed an admission date of 05/10/17. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. Resident #42 was totally dependent on staff for toileting. Review of the care plan dated 06/01/23 revealed Resident #42 was completely incontinent for bowel and bladder. Observation on 09/21/23 at 10:37 A.M. with State Tested Nursing Aide (STNA) #132 revealed she provided the incontinence care for Resident #42 while STNA #138 assisted with the repositioning Resident #42. STNA #132 took a washcloth, sprayed wash on the front part of Resident #42, and proceeded to wipe down the right and left side of the legs in a downward motion but STNA #138 didn't wash the scrotum or the penis. Interview with the STNA #132 on 09/21/23 at 10:56 A.M. verified she did not wash Resident #42's penis or scrotum during incontinence care and stated it was not her practice to not wash the penis or the scrotum. She stated at times the men will get an erection but stated she should still clean the area to prevent infection. Interview with STNA #138 on 09/21/23 at 11:00 A.M. revealed she did not see anything wrong with the way the aide cleaned Resident #42. Review of the facility policy titled Incontinence Care Protocol, dated 09/01/17, revealed the facility will provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor, and providing comfort and self-esteem for the resident. The policy further revealed after each incontinence episode to cleanse the ate area with perineal wash and pat dry. This deficiency represents non-compliance investigated under Complaint Number OH00146155. 366387 Page 3 of 3