Health inspection·June 8, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 the minimum data set log, and review of the resident assessment instrument (RAI) manual, the facility failed to ensure resident assessments were completed quarterly. This affected three residents (#05, #20 and #32) of four residents reviewed for timely assessments. The facility census was 52. Residents Affected - Few Findings Include: 1. Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, and depressive disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #05 should have had a quarterly MDS completed on 08/02/22 and it was completed on 09/06/22. The previous quarterly MDS was completed on 05/23/22. This was 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, and hypertension. Review of the MDS comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #20 should have had a quarterly MDS assessment completed on 04/12/23 and it was completed on 05/19/23. The previous quarterly MDS was completed on 01/10/23. This 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, and acute respiratory failure. Review of the MDS comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #32 should have had a quarterly MDS assessment completed on 04/28/23 and it was completed on 06/05/23. The previous MDS assessment was completed upon Interview on 06/08/23 at 2:55 P.M., the Assistant Director of Nursing (ADON) #17 verified the MDS assessments for Resident #05, #09, #20 and #32 had been completed greater than 90 days from the previous MDS completion. Review of the RAI manual revealed a quarterly assessment would need to be completed no more than 92 days after the most recent Omnibus Budget Reconciliation Act (OBRA) assessment. Page 1 of 5 366417 366417 06/08/2023 Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160

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, review of signage on the resident unit refrigerators, and policy review, the facility failed to ensure foods were safely stored. This had the potential to affect all 52 residents who received food from the kitchen. The facility census was 52. Findings include: Observation on 06/05/23 at 9:00 A.M. revealed the following kitchen sanitation issues: - In the milk cooler, twenty five eight ounce individual serving cartons of chocolate milk with an expiration date of 06/03/23. - In the walk in refrigerator, there was no internal thermometer. There were eight glasses of orange fluid undated and unlabeled, two pitchers of fluid unlabeled and undated and four containers, labeled as pudding, undated. Observation on 06/07/23 at 8:07 A.M., revealed the following Unit 300 resident refrigerator sanitation issues: - There was no thermometer in the resident refrigerator. - There was an insulated lunchbag, undated and unlabeled. - There was two containers of unidentifiable food unlabeled and undated. Observation on 06/07/23 at 8:10 A.M., revealed the following Unit 100 resident refrigerator sanitation issuess: - There was no thermometer in the freezer - There was one unopened expired milk carton dated 06/05/23. - There was one opened container labeled as fruit dip with no open date and an expired date of 05/21/23. - There was one bowl of identified dry cereal undated and unlabeled. Interview on 06/05/23 at 9:15 A.M., [NAME] #11 verified the sanitation conditions in the walk in refrigerator. [NAME] #11 verified the expired foods should have been discarded and all foods should be labeled, dated, and marked with an open date. Interview on 06/07/23 at 8:10 A.M, the Assistant Director of Nursing (ADON) #17 verified the Unit 100 and the Unit 300 resident refrigerators were designated for resident food storage and for staff food items. The ADON #17 said the expired foods should have been discarded and all foods should have been labeled and dated. Review of a sign attached to the front of the Unit 100 and the Unit 300 resident refrigerators 366417 Page 2 of 5 366417 06/08/2023 Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many revealed the refrigerator shoulde be cleaned out every Tuesday. All foods must be marked with name, date and the date the item was opened. Staff must put their name on their items. Review of the policy titled Food Storage, undated revealed all food shall be covered, labeled, and dated. Every refrigerator must be equipped with an internal thermometer. Refrigerators on the nursing floors will be monitored by nursing. 366417 Page 3 of 5 366417 06/08/2023 Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 06/08/23 at 1:17 P.M. revealed Resident #01 and #12's room had gouges, missing drywall and paint by wall by Resident #01's bed. The room also had gouges and missing paint on the wall by the bathroom. Interview with Registered Nurse #72 on 06/08/23 at 1:17 P.M. verified the observation in Resident #01 and #12's room. Observation on 06/08/23 at 1:19 P.M. revealed Resident #103's room had scuffs and missing drywall around the baseboard in the bathroom. Interview with Registered Nurse #72 on 06/08/23 at 1:19 P.M. verified the observation in Resident #103's room. Based on medical record review, observation and staff and resident interview, the facility failed to ensure the resident environment was sanitary. This affected eight residents (#01, #04, #12, #16, #44, #45, #46 and #103) of 52 residents' room environment observed. In addition, the facility failed to ensure the floors were in good repair. This had the potential to affect 31 of 31 residents who could independently ambulate. The facility identified 21 residents (#01, #09, #07, #22, #20, #14, #23, #47, #08, #41, #02, #36, #15, #19, #39, #06, #07, #09, #35, #11 and #38) who were unable to independently ambulate in the facility. The facility census was 52. Findings Include: 1. Review of the medical record revealed Resident #04 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, diabetes, chronic pain, and psychotic disturbance. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #04 had moderately impaired cognition. The resident was non ambulatory and required assistance for locomotion in wheelchair. Observation on 06/05/23 at 1:33 P.M. revealed Resident #04 lying in bed facing a wall with several deep gouged exposed areas measuring from one inch to eight inches long, four inches by two inches, and one inch by six inches. The areas exposed drywall. There was also eight inches of baseboard missing at the bottom of the wall with debris. Interview 06/05/23 at 1:33 P.M., Resident #04 revealed the areas had been exposed and had not been repaired since she had been at the facility. She did not like looking at the areas from her bed. 2. Observation on 06/05/23 at 9:00 A.M. through 06/7/23 at 1:20 P. M revealed Resident #16, #44, #45, and #46's rooms had two inch by 12 inch strips of exposed drywall on both sides of the wall near the hallway door frame. The areas were a non-cleanable surfaces. Interview on 06/07/23 at 8:40 A.M., the Maintenance Director (MD) #73 verified Resident #04's baseboard was missing and collected debris. He stated the wall gouges had not been repaired for three weeks and the repair would take about a week. The MD #17 verified the rooms of Residents' #16, #44, #45, and #46 had exposed drywall near the doorframes. He stated there had been attached signage removed from those resident rooms walls about three weeks ago and the exposed walls were a non-cleanable 366417 Page 4 of 5 366417 06/08/2023 Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160

F 0921 surface. Level of Harm - Minimal harm or potential for actual harm 4. Observation on 06/05/23 at 9:00 A.M. through 06/07/23 at 1:20 P.M. revealed the floor surrounding the 100, the 200 and the 300 nurses' stations had linoleum flooring with exposed subflooring and jagged edges. The areas of disrepair ranged from two inches by 12 feet, one inch by two feet and one inch by six feet. There was noted debris along the jagged edges of the linoleum. Observations on 06/05/23 through 06/07/23 at varied times revealed residents ambulating on the exposed flooring at the 100, the 200 and the 300 unit nursing station areas. Residents Affected - Some Interview on 06/07/23 at 8:40 A.M., the MD #73 verified the linoleum flooring surrounding the 100, the 200 and the 300 nurses' stations was in disrepair, making it difficult to clean, and had debris in the jagged edging. He stated the floor was separating at the seams of the linoleum and needed repaired. 366417 Page 5 of 5