Health inspection·June 18, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility transfer notices, the facility failed to ensure appropriate transfer/discharge notifications were made to the state Ombudsman office. This affected three residents (#16, #22 and #23) of three resident records reviewed for discharge. The census was 18. Findings include: 1. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hydrocephalus, Alzheimer's disease with early onset, depression, dysarthria, and anarthria. Review of Resident #16's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired. He required supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. Review of Resident #16's physicians orders revealed an order to discharge the resident home with Physical Therapy, Occupational Therapy, Speech Therapy, a home health aide and nursing services with current medications on 01/13/25. Review of the progress notes revealed on 01/13/25 at 1:10 P.M., Resident #16 was discharged from the facility via a family car accompanied by his sister. Review of facility documentation, transfer notices, and the residents medical record revealed there was no documented evidence that the Office of the State Long Term Care (LTC) Ombudsman was aware/notified of Resident #16's transfer/discharge. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing verified the Ombudsman was not notified of Resident #16's discharge. 2. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, bacterial pneumonia, anxiety, dementia, stage three chronic kidney disease, and atrial fibrillation. Review of Resident #22's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required supervision or touching assistance for eating, oral hygiene and personal hygiene and substantial/maximal assistance for toileting and shower/bathing. Page 1 of 6 366411 366411 06/18/2025 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0628 Level of Harm - Minimal harm or potential for actual harm Review of Resident #22's physicians orders revealed an order on 03/18/25 to discharge the resident to the Assisted Living. Review of the progress notes dated 03/18/25 at 11:16 A.M. revealed Resident #22 was discharged from the facility at 10:00 A.M. via a family car accompanied by his daughter. Residents Affected - Few Review of facility documentation, transfer notices, and the residents medical record revealed there was no documented evidence that the Office of the State Long Term Care (LTC) Ombudsman was aware/notified of Resident #22's transfer/discharge. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing verified the Ombudsman was not notified of Resident #22's discharge. 3. Review of Resident #23's medical record revealed they were admitted to the facility on [DATE]. Diagnoses included fracture of the pelvis/sacrum, high blood pressure, diabetes, and osteoporosis. Review of Resident #23's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was intact. She was independent with eating, required set up or clean up assistance with oral hygiene, and required substantial/maximal assistance with toileting, shower/bathing, and dressing. It also noted she was occasionally incontinent of bladder and frequently incontinent of bowel. Review of the progress notes dated 04/16/25 at 6:20 A.M. revealed Resident #23 had two to three bowel movements today that were watery, mixed with some small 'round' hard stool, and it still felt like she had to 'go'. The resident declined being taken to the toilet to try to go. Fluids were encouraged in moderation. Abdominal bowel sounds were noted in the upper two quadrants, but nothing was heard in the lower right quadrant and very little was heard in the lower left quadrant. It stated she felt firm in the lower quadrant and it was painful when palpated. The on-call physician was notified and ordered a STAT kidneys, ureters and bladder (KUB) diagnostic test or to send the resident for an evaluation if the resident was having increased pain. The resident stated she wanted to go to the hospital. She was admitted to the hospital with a urinary tract infection (UTI). Review of facility documentation, transfer notices, and the residents medical record revealed there was no documented evidence that the Office of the State Long Term Care (LTC) Ombudsman was aware/notified of Resident #23's transfer/discharge. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing verified the Ombudsman was not notified of Resident #23's discharge. 366411 Page 2 of 6 366411 06/18/2025 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed as required. This affected one resident (#16) of 17 residents records reviewed for MDS assessments. The census was 18. Findings include: Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hydrocephalus, Alzheimer's disease with early onset, depression, dysarthria and anarthria. Review of Resident #16's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired. He required supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. It also noted he was occasionally incontinent of urine and always continent of bowel. Review of Resident #16's physicians orders revealed an order to discharge the resident home with Physical Therapy, Occupational Therapy, Speech Therapy, a home health aide and nursing services with current medications on 01/13/25. Review of the progress notes revealed on 01/13/25 at 1:10 P.M., Resident #16 was discharged from the facility via a family car accompanied by his sister. Further review of the medical record for Resident #16 revealed there was no discharge MDS assessment completed. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing confirmed a discharge MDS assessment was not completed for Resident #16. 366411 Page 3 of 6 366411 06/18/2025 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed as required. This affected one resident (#16) of 17 residents records reviewed for MDS assessments. The census was 18. Residents Affected - Few Findings include: Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hydrocephalus, Alzheimer's disease with early onset, depression, dysarthria and anarthria. Review of Resident #16's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired. He required supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. It also noted he was occasionally incontinent of urine and always continent of bowel. Review of Resident #16's physicians orders revealed an order to discharge the resident home with Physical Therapy, Occupational Therapy, Speech Therapy, a home health aide and nursing services with current medications on 01/13/25. Review of the progress notes revealed on 01/13/25 at 1:10 P.M., Resident #16 was discharged from the facility via a family car accompanied by his sister. Further review of the medical record for Resident #16 revealed there was no discharge MDS assessment completed. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing confirmed a discharge MDS assessment was not completed for Resident #16. 366411 Page 4 of 6 366411 06/18/2025 Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and review of facility menu spreadsheets, the facility failed to provide a varied menu for a resident on a pureed diet. This affected one resident (Resident #7) and had the potential to affect two residents (#1 and #7) receiving a pureed diet. The facility census was 18. Findings include: Review of Resident #7's medical record revealed that she was admitted on [DATE] with diagnoses that included dysphagia and gastrostomy status. Review of Resident #7's Minimum Data Set (MDS) significant change assessment dated [DATE] revealed that she had intact cognitive status. Review of Resident #7's physician orders dated 06/10/25 revealed that she was on a regular diet of pureed consistency and thin liquids. Review of the pureed menu spreadsheets from 04/06/25 through 05/18/25 (42 days), approved by Registered Dietitian #110, revealed that green beans were served 20 times and mashed potatoes were served 34 times. Interview with Resident #7 on 06/16/25 at 9:59 A.M. and on 06/18/25 at 9:23 A.M. revealed that she felt that there was no variety in the pureed diets. She stated that she received mashed potatoes and/or green beans every day. Observation on 06/16/25 at 11:48 A.M. revealed that Resident #7 was served mashed potatoes at her lunch meal. Resident #7 was overheard saying to Certified Nursing Aide (CNA) #75 that she wished that she could have been served the pureed version of the starch that the regular textured diet residents were served at that meal, which was sweet potato fries. CNA #75 did not offer to serve her an alternative food item. Interview with CNA #76 on 06/17/25 at 10:21 A.M. revealed that the same items were usually served for lunch and dinner for pureed meals, with little variety offered. She stated that there was usually always mashed potatoes on the plate. Interview with CNA #75 on 06/17/25 at 10:27 A.M. revealed that residents who were served pureed textures seemed to receive the same meals repeatedly, with little variety. She stated that she had brought it to the dietary department's attention on repeated occasions in the past, but that nothing changed. Interview with Registered Dietitian #110 on 06/18/25 at 11:19 A.M. revealed that upon review of the pureed diet menu spreadsheets, green beans were served too frequently. She also confirmed that there were other alternatives for mashed potatoes, as a starch, that could have been used for pureed options. 366411 Page 5 of 6 366411 06/18/2025 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. Based on observation, staff interview, and review of facility policy, the facility failed to prepare pureed diets at the proper consistency. This had the potential to affect two residents (Resident #1 and #7) that the facility identified as receiving a pureed diet consistency. The facility census was 18. Findings include: Interview with Sous Chef #112 on 06/17/25 at 11:04 A.M. revealed that all pureed foods should be served at a smooth pudding-like consistency with no chunks. Observation and interview on 06/17/25 at 11:03 A.M. revealed Line [NAME] #115 began the preparation of the pureed chicken tenders. At 11:10 A.M., Line [NAME] #115 indicated verbally that the chicken tenders were at puree consistency and ready to be tested. Observation via taste of the pureed chicken tenders on 06/17/25 at 11:10 A.M. revealed that there were visible lumps and chunks in the puree chicken tenders, and that the consistency was not homogenous. Interview with Sous Chef #112 on 06/17/25 at 11:10 A.M. verified that the puree chicken tenders had chunks in them. Observation and interview on 06/17/25 from 11:10 A.M. to 11:17 A.M. revealed that Line [NAME] #115 continued to process the pureed chicken tenders. At 11:17 A.M., Line [NAME] #115 indicated that the food was ready to be tested again. Observation via taste of the pureed chicken tenders on 06/17/25 at 11:17 A.M. revealed that there were still visible lumps and chunks in the puree chicken tenders, and that the consistency was still not homogenous. Interview with Sous Chef #112 on 06/17/25 at 11:17 A.M. confirmed that there were still chunks in the pureed chicken tenders. Interview with Executive Chef #150 on 06/17/25 at 11:30 A.M. revealed that the pureed chicken for the meal should have been unbreaded chicken, as the breading on the cooked chicken tenders is tough to break down mechanically into a pureed texture. He indicated that he would educate the dietary staff about not using breaded chicken for pureed textures. Review of the undated facility policy titled Texture and Consistency Modified Diets revealed that the food and nutrition services department will be responsible for preparing and serving the correct consistency of food and beverages as ordered. 366411 Page 6 of 6