Health inspection·February 21, 2019

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 interview the facility failed to ensure residents had the right to refuse or discontinue treatment when they failed to have matching cardiopulmonary resuscitation code status documentation. This affected three (#3, #5 and #7) of 16 residents reviewed for code status. The facility census was 27. Findings include: 1. Medical record review of Resident #5 revealed an admission date of: [DATE] with pertinent diagnoses of: fracture of lumbar vertebrae, muscle weakness, dementia without behaviors, insomnia, hypertension glaucoma, vitamin deficiency, and depressive episodes. Review of a paper Do Not Resuscitate (DNR) comfort care form dated [DATE] revealed the resident was requesting a Do No Resuscitate Comfort Care-Arrest (DNR-CCA) code status. Review of Resident #5's electronic medical record on [DATE] at 5:02 P.M. revealed a current Physicians Order for the Resident to be a full code and receive cardiopulmonary resuscitation (CPR). Interview with the Director Of Nursing (DON) on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 2. Medical record review for Resident #3 revealed an admission date of [DATE] with pertinent diagnoses including: paralytic ileus, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, and diabetes mellitus type two. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician Order on [DATE] revealed the Resident was requesting a DNRCC code status. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 3. Medical record review of Resident # 7 revealed an admission date of [DATE] with pertinent diagnoses of: diabetes mellitus type two, muscle weakness, hypertension, hypothyroidism, and hyperlipidemia. Page 1 of 7 366415 366415 02/21/2019 Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177

F 0578 Level of Harm - Minimal harm or potential for actual harm Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician Order on [DATE] at 4:12 P.M. revealed the Resident was requesting a DNRCC code status. Residents Affected - Few Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 366415 Page 2 of 7 366415 02/21/2019 Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview the facility failed to ensure residents received the appropriate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form when they were cut from skilled services and remained in the facility. This affected two (#20 and #22) of three residents reviewed for beneficiary notices. The facility census was 27. Residents Affected - Few Findings include: 1. Medical record review for Resident #22 revealed an admission date 12/31/18 with pertinent diagnoses of pneumonia, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage, dysphagia, anemia, benign prostatic hyperplasia, hyperlipidemia, hypertension, type two diabetes mellitus, and cerebral infarction. Review of a Notice of Medicare Non Coverage (NOMNC) form dated 02/15/19 revealed Resident #22 was cut from nursing and therapy services on 02/18/19 and remained in the facility. Interview with the Director of Nursing (DON) on 02/21/19 at 1:05 P.M. verified that Resident #22 remained in the facility and had skilled nursing days remaining. The DON verifed the resident did not received the SNFABN. 2. Record review for Resident #20 revealed an admission date of 07/20/18 with pertinent diagnoses of: hypertension, cerobrovascular accident, hemiplegia, mild cognitive impairment, osteoporosis, and atrial fibrillation. Review of a NOMNC dated 09/13/18 revealed Resident #20 was cut from nursing and therapy services on 09/17/18 and remained in the facility. Interview with the DON on 02/21/19 at 1:05 P.M. verified Resident #20 remained in the facility and had skilled nursing days remaining. The DON verified the resident did not receive SNFABN. 366415 Page 3 of 7 366415 02/21/2019 Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177

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 facility policy review the facility failed to ensure foods were stored in accordance with professional standards when they stored food scoops in the containers. This had the potential to affect 26 Residents who ate from the kitchen. The facility identified Resident #10 who did not eat anything by mouth. The facility census was 27. Findings include: Observation of the main Kitchen on 02/19/19 at 9:40 A.M. revealed scoops were stored in the food containers for flour, rice, and sugar. The scoops were stuck in the food items with the scoop handle visible. Interview with Dietary Worker #35 at the time of the interview verified the food scoops were stored inside the flour, rice and sugar containers and the scoops were stuck in the food with the scoop handle visible. Review of a facility undated food storage policy revealed scoops are not to be stored in food containers but are kept in a protected area near or in the containers. 366415 Page 4 of 7 366415 02/21/2019 Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and facility training audit form the facility failed to dispose of garbage and refuse properly when they left the dumpster lids open and had trash around the dumpster area. This had the potential to affect all 27 residents residing in the facility. Residents Affected - Few Findings include: Observation on 02/21/19 at 10:55 A.M. revealed the dumpster lids were open and there was a wooden pallet and trash on the ground beside the dumpster. Interview with Dietary Worker #35 at the time of the observation verified the dumpster lids were open and there was a wooden pallet and trash on the ground beside the dumpster. Review of an undated facility form titled Dining Food Safety and Training audit revealed the dumpster is maintained to minimize sanitation issues, and lids are on the dumpster. 366415 Page 5 of 7 366415 02/21/2019 Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177

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 ensure residents records were accurate when the code status was not accurate. This affected three (#3, #5 and #7) of 16 residents reviewed for code status. The facility census was 27. Findings include: 1. Medical record review of Resident #5 revealed an admission date of: [DATE] with pertinent diagnoses of: fracture of lumbar vertebrae, muscle weakness, dementia without behaviors, insomnia, hypertension glaucoma, vitamin deficiency, and depressive episodes. Review of a paper Do Not Resuscitate (DNR) comfort care form dated [DATE] revealed the resident was requesting a Do No Resuscitate Comfort Care-Arrest (DNR-CCA) code status. Review of Resident #5's electronic medical record on [DATE] at 5:02 P.M. revealed a current Physicians Order for the Resident to be a full code and receive cardiopulmonary resuscitation (CPR). Interview with the Director Of Nursing (DON) on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 2. Medical record review for Resident #3 revealed an admission date of [DATE] with pertinent diagnoses including: paralytic ileus, hemiplegia and hemiparesis affecting right dominant side, muscle weakness, and diabetes mellitus type two. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician Order on [DATE] revealed the Resident was requesting a DNRCC code status. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 3. Medical record review of Resident # 7 revealed an admission date of [DATE] with pertinent diagnoses of: diabetes mellitus type two, muscle weakness, hypertension, hypothyroidism, and hyperlipidemia. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician Order on [DATE] at 4:12 P.M. revealed the Resident was requesting a DNRCC code status. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician Order and the Paper form. 366415 Page 6 of 7 366415 02/21/2019 Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and facility policy review the facility failed to maintain essential mechanical equipment in safe operating order when the kitchen stove hood and filters were dirty and covered with grease. This had the potential to affect all 27 facility residents. Residents Affected - Many Findings include: Observation of the main kitchen on 02/19/19 at 9:40 A.M. revealed grease running down the hood, hood filters, and the back wall overtop the cooking area. Interview with Dietary Worker #35 at the time of the observation verified there was grease running down the hood, hood filters, and the back wall overtop the cooking area. Review of an undated facility policy titled cleaning hoods and filters revealed stove hoods and filters will be cleaned at least monthly and according to the cleaning schedule. 366415 Page 7 of 7