Health inspection·June 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure Resident #129's indwelling urinary catheter bag was covered for dignity and privacy. This affected one resident (#129) of one resident reviewed for dignity related to urinary catheter bags. The facility identified four residents (#6, #12, #129, and #178) with urinary catheters. The facility census was 22. Findings include: Review of the medical record for the Resident #129 revealed an admission date of 05/31/23. Diagnoses included wedge compression fracture, diabetes, epidural hemorrhage, dementia, and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] was still in process and had not yet been completed. Review of the physician's order dated 05/24/23 revealed resident had an indwelling urinary catheter and required catheter care. Observation on 05/30/23 at 2:20 P.M. revealed Resident #129 had a urinary catheter. The urinary catheter bag contained urine and was hanging below the bed and visible from the hallway. Resident #129's urinary catheter bag did not have a privacy cover. Observation on 05/31/23 at 9:19 A.M., 10:50 A.M., 2:00 P.M. and 3:40 P.M. revealed Resident #129 had a urinary catheter bag that was left uncovered and visible from the hallway. Interview on 05/31/23 at 3:40 P.M. with Unit Manager #173 and the Director of Nursing (DON) confirmed the facility had urinary catheter bag covers, and urinary catheter bags should be maintained with a privacy cover. Unit Manager #173 and the DON confirmed Resident #129 did not have a urinary catheter bag privacy cover in place. Page 1 of 9 366411 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

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 resident interview, staff interview, record review, and facility policy review the facility failed to ensure Resident #14 was offered an initial care conference. This affected one resident (#14) of two residents reviewed for care conferences. The facility census was 22. Findings include: Review of the medical record for Resident #14 revealed a readmission date of 05/09/23. Diagnoses included chronic obstructive pulmonary disease, diabetes, Fournier's gangrene, vascular disease, muscle weakness, and colostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact with and required limited to extensive assistance of one staff member for all activities of daily living and mobility. Interview on 05/30/23 at 1:52 P.M. with Resident #14 revealed he would like to participate in care conference meetings and would like his daughter to be invited as well. Resident #14 reported he had not been invited to any care conferences since admission in 04/2023 and reported he was hospitalized and returned 05/09/23. Review of the medical record revealed no documented evidence of a care conference for Resident #14. Interviews on 05/31/23 at 2:08 P.M. and 3:09 P.M. with Social Services (SS) #160 revealed the facility offers a care conference within two weeks of admission to discuss the plan for admission. SS #160 revealed a large majority of residents are short-term and are admitted for rehabilitation services. SS #160 confirmed Resident #14 did not have a care conference due to SS #160 being on vacation. SS #160 revealed no current plan to hold a care conference for Resident #14. Review of the undated facility policy titled Care Conference revealed a purpose to include residents and representatives in the planning process. 366411 Page 2 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interviews, medical record review, and review of the facility's discharge policy and procedure, the facility failed to notify the Ombudsman when residents were discharged from the facility. This affected three residents (#10, #16 and #78) out of three residents reviewed for discharges. The facility census was 22. Findings include: Review of Resident #10's medical record revealed an admission date of 4/22/23 with a fractured right clavicle, cerebral infarction, and type two diabetes. He was discharged on 05/12/23. Review of Resident #16's medical record revealed an admission date of 4/15/23. Diagnoses of unspecified fracture part of the neck, osteoporosis with pathological fracture of the vertebra, and emphysema. Resident #16 was discharged home on 5/15/23. Review of Resident #78's medical record revealed an admission date of 03/07/23 for rehabilitation. Diagnoses included chronic cholecystitis, type two diabetes, emphysema, and congestive heart failure. He was discharged from the facility on 04/18/23. Interview on 05/31/23 at 11:49 A.M. with Licensed Social Worker (LSW) #179 revealed she does not notify the Ombudsman when residents are discharged from the facility to home. Interview on 05/31/23 at 2:00 P.M. with the Administrator revealed it is not policy to notify the ombudsman when residents are discharged to home. Review of the undated Facility's Discharge Planning policy revealed no indication the Ombudsman should be notified when a resident was to be discharged from the facility. 366411 Page 3 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

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, staff interview, record review, and facility policy review the facility failed to ensure Resident #21 received timely and appropriate care to prevent weight loss including obtaining weights as ordered, providing supplements as ordered, and providing meals according to the meal ticket. This affected one resident (#21) of one resident reviewed for nutrition. The facility census was 22. Residents Affected - Few Findings include: Review of the medical record for Resident #21 revealed an admission date of 04/26/23. Diagnoses included normal pressure hydrocephalus, muscle weakness, malnutrition, and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired and required extensive assistance of two staff members for transfers. The MDS revealed the resident had a deep tissue injury (DTI) pressure ulcer to the right heel (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear.) Review of the plan of care dated 05/25/23 revealed Resident #21 was at risk for alteration in nutrition with a goal to maintain weight without significant weight loss with interventions to provide supplements as ordered, nutrition to be monitored as needed (labs, weights, and intakes), and menu with preferences. Review of physician orders for revealed the following orders: • 04/26/23 to 05/10/23 revealed diet order of regular texture and regular consistency. • 04/27/23 Remeron 15 milligrams (mg) tablet with instructions to give one-half tablet at bedtime for appetite stimulant. • 05/01/23 Ensure with meals for supplement. • 05/03/23 weekly weights for four weeks then monthly with instructions to notify the provider and reweigh for a two-to-five-pound weight difference. • 05/10/23 regular diet mechanical soft texture. • 366411 Page 4 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0692 05/24/23 Magic cup (supplement) twice daily 120 milliliters (ml) with instructions to give at lunch and dinner. Level of Harm - Minimal harm or potential for actual harm • 05/25/23 for Marinol oral capsule 2.5 mg twice daily for appetite stimulant. Residents Affected - Few Review of resident weights included: • 04/26/23 - 94.8 pounds (lbs.) • 05/03/23 - 93.4 lbs. • 05/10/23 - 94.4 lbs. • 05/24/23 - 85.0 lbs. There was a significant weight loss of 10.34 percent (%) in 30 days, and review of medical record found no documented evidence a reweight being obtained. Review of the progress notes dated 05/24/23 revealed a weight change reflecting a significant weight loss of 10.3% over 30 days, resident with poor intake with supplements and an unstageable DTI pressure wound to the right heel with plan to add Magic cup 120 ml with lunch and dinner for nutritional support. On 05/26/23 Marinol oral capsule 2.5 mg was added with instructions for one capsule by mouth every morning and at bedtime for appetite stimulant. On 05/27/23, Marinol oral capsule 2.5 mg with instructions to give one capsule in morning and night for appetite stimulant was ordered, and the facility was waiting for it to be delivered. Observation on 05/30/23 at 11:58 A.M. of the lunch meal revealed Resident #21 did not receive the Magic cup supplement on her tray. Review of Resident #21's meal ticket dated 05/31/23 for lunch revealed the resident had an order for mechanical soft food and instructions for food to be cut into bite size pieces. The supplements were not included on the meal ticket. Observation on 05/31/23 at 11:47 A.M. of the lunch meal revealed Resident #21 did not receive the Magic cup supplement on her tray. Resident #21's meal ticket also stated a mechanically soft diet order and instructions for food to be cut into bite size pieces. Interview on 05/31/23 at 12:01 P.M. with State Tested Nursing Aide (STNA) #119 revealed the kitchen staff make sure Magic cups are available and placed on the trays, and aides pass out the Ensure 366411 Page 5 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0692 Level of Harm - Minimal harm or potential for actual harm supplements. STNA #119 confirmed Resident #21's Magic cup was not provided with the lunch meal as ordered and confirmed the resident's dessert was not cut into bite size pieces and reported typically resident's food had not been cup up. STNA #119 revealed typically Resident #21 ate about 25% of her meals and required significant encouragement. STNA #119 verified all weights taken by STNA's were entered into the electronic medical record. Residents Affected - Few Interview on 05/31/23 at 2:28 P.M. with Dietitian #177 revealed being scheduled at the facility two days weekly and meets with residents at the beginning of their admission to discuss preferences and dietary concerns. Dietitian #177 revealed Resident #21 was not able to participate in the assessment due to poor cognition. Dietitian #177 reported she reviewed weights for Resident #21 and recognized a weight was missing on 05/17/23 and requested that nursing staff get this weight the next day. Dietitian #177 reported the weight was not obtained until 05/24/23 and was found to have a significant weight loss. Dietitian #177 revealed all residents should have orders for weekly weights for four weeks and then monthly weights ongoing and revealed regular issues with getting staff to complete resident weights as ordered. Dietitian #177 revealed she was unaware of medication recommendations for an appetite stimulant and confirmed several progress notes related to medication Marinol not being provided due to awaiting pharmacy delivery. Dietitian #177 revealed she was unaware of the Magic cup was not being given as ordered. Interview on 06/01/23 at 4:32 P.M. with the Director of Nursing (DON) revealed the Magic cup was marked off as given with breakfast. The DON confirmed this did not match the physician's order. Review of the undated facility policy titled Weights and Weight Change Management revealed residents would be weight monthly unless ordered by a physician or recommended by a dietitian. The weight will be documented in the medical record and weight changes will be addressed by the dietitian and interdisciplinary team. Residents would be re-weighed if a significant weight loss was noted. 366411 Page 6 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files and interviews the facility failed to complete employee evaluations for four of four State Tested Nurse's Aides (STNAs) reviewed for personnel files (STNAs #130, #134, #148, and #164). This had the potential to affect all facility residents. The facility census was 22. Residents Affected - Many Findings include: 1. Review of personnel file for STNA #164 hired on 02/01/21 had no evidence of a 90-day evaluation or an annual evaluation since hire. 2. Review of personnel file for STNA #130 hired on 03/21/22 had no evidence of a 90-day evaluation or an annual evaluation since hire. 3. Review of personnel file for STNA #134 hired on 04/21/22 had no evidence of a 90-day evaluation or an annual evaluation since hire. 4. Review of personnel file for STNA #148 hired on 02/21/23 had no evidence of a 90-day evaluation since hire. Interview on 06/01/23 at 3:20 P.M. with Director of Human Resources #175 revealed facility was not doing any performance evaluations since the start of the COVID-19 pandemic and revealed they had recently restarted performance evaluations for newly hired staff but revealed no process in place to evaluate previously hired employees. Interview on 06/01/23 at 4:32 P.M. with the Director of Nursing (DON) revealed the facility had no policy related to staff evaluations. 366411 Page 7 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review the facility failed to ensure pureed foods were made to the correct consistency and according to the recipe. This affected one resident (#6) who was the only resident with pureed diet orders. The facility census was 22. Findings include: Review of the medical record for Resident #6 revealed an admission date of 03/17/23 with diagnosis including a stroke. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired and required limited assistance from staff for eating. Observation on 05/31/23 at 11:19 A.M. revealed Dietary Staff #180 when making the puree pasta with meat sauce, placed two handfuls of pasta noodles into the food processor. Then added 2.5 scoops of spaghetti with meat sauce using a 6-ounce (oz) scoop and blended the mixture. Then Dietary Staff #180 added approximately one-half tablespoon of thickener to the mixture. After blending the mixture, the pureed food was at the bottom of the food processor and pieces of food and noodle that had not been blended or pureed were on the top and sides of the food processor. When Dietary Staff #180 scraped the pureed mixture into the dishes to be placed on the warming cart, the chunks of noodle were also scraped into the metal container and were visible sticking out of the pureed food. Interview on 05/31/23 at 11:23 A.M. with Dietary Staff #180 and Dietary Manager #136 confirmed the pureed food contained whole pieces of about 1-inch-long noodles. Review of the Pureed Recipe instructions revealed food should be processed until fine in texture and instructions to scrape down sides with a spatula and reprocess. Review of the undated facility policy titled Therapeutic Diet revealed a purpose to assure residents receive and consume food in the appropriate form as prescribed. Review of the undated facility policy titled Texture and Consistency Modified Diets revealed a purpose for texture and consistency-modified diets should be individualized with modifications. The policy revealed the food and nutrition services department would be responsible for preparing and serving the correct consistency of food as ordered and per the recipe. 366411 Page 8 of 9 366411 06/01/2023 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review the facility failed to ensure safe and sanitary storage of all food materials in the dry storage, refrigerator, and freezer areas. This had the potential to affect all 22 residents as they all received food from the kitchen. The facility census was 22. Findings include: Observation and interview on 05/30/23 at 9:39 A.M. with Dining Staff #144 in the unit kitchenettes revealed: • frozen pancakes with no date • unsealed ice cream • a yellow liquid substance in a bottle in dry storage with no label and no date • several spice containers that expired 03/21/18 Interview with Dining Staff #144 at the time of the observations confirmed the above findings. Observation and interview on 05/20/23 at 10:45 A.M. with Dietary Manager #136 in the main kitchen revealed six bottles of lime juice were found to have expired 02/27/23. Dietary Manager #136 confirmed the finding at the time of the observation. Review of the facility policy titled Food Supply and Storage Procedures, dated 10/13/12, revealed all food shall be stored in such a manner as to maintain the safety for human consumption. Products should be discarded after the used by date has passed and cannot be served to residents after the sell by date has passed. All food items should be covered, labeled, and dated as appropriate. 366411 Page 9 of 9