Health inspection·May 4, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, and review of the facility missing item log, the facility failed to follow up with Resident #41 who verbalized a personal item was missing. This affected one (Resident #41) of the two residents reviewed for missing personal property. Findings include: Review of the medical record for Resident #41 revealed an admission date of 07/24/20. Diagnoses included chronic kidney disease stage 5, acute and chronic respiratory failure, and hypertensive chronic kidney disease. Review of Resident #41's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident with a Brief Interview for Mental Status score of 15 indicating an intact cognition for daily decision making. Resident #41 required extensive assistance from two staff members for bed mobility and personal hygiene, and one staff member for dressing, and toilet use. Review of Resident #41's Plan of Care dated 08/28/20, revealed the resident is at risk for a decline in cognition due to encephalopathy. Interventions included to allow the resident to make choices in own activities and daily routine. Interview on 04/27/21 at 10:59 A.M. with Resident #41 revealed she had a [NAME] that a family member who lived far away had made for her and it was missing. The resident stated this missing item was reported but she had not received any updates about how the facility was going to take care of the missing item since it can not be replaced. Interview on 05/03/21 at 2:30 P.M. with the Administrator confirmed he had been notified of Resident #41's personal item and still needed to follow up with that resident about how she would like to have it replaced. Review of the facility's missing item log revealed Resident #41's [NAME] was reported missing on 04/09/21 and had not been found or replaced as of this time. Page 1 of 12 366430 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, resident council minutes review, and call light audit review, the facility failed to ensure Resident #8's call light was functioning properly and answered timely. This affected one (Resident #8) of the one resident reviewed for accommodation of needs. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/19/20. Diagnosed included Rheumatoid Arthritis, weakness, and Osteomyelitis of vertebra, sacral region. Review of Resident #8's Medicare 5 day Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had an intact cognition for daily decision making. Resident #8 required extensive assistance from one staff member for bed mobility, dressing, eating, and toilet use. Review of the facility Resident Council minutes for 04/09/21, revealed Resident #8 had a concern that call lights never get answered. Interview and observation on 04/26/21 at 11:00 A.M. with Resident #8 revealed when she turns on her call light no one comes to help her most of the time so she no longer uses her call light but instead calls the front desk to let them know she needs something and they will contact the staff member assigned to her to let them know she needs something. Resident #8 revealed this has been an ongoing issue. Upon receiving this information, Resident #8 was asked to activate her call light which upon doing so, a red light was noted to appear on the call light pendent. While completing this interview, Resident #8 received a phone call from the facility and Resident #8 was heard telling the person on the phone that she needed someone to come to her room for help. After hanging up the phone, Resident #8 revealed she had called the front office prior to the interview and had to leave a voice message and that was them calling her back. Interview and survey questions continued with Resident #8 from 11:00 A.M. till 11:48 A.M. During this time, Resident #8's call light had not been answered nor had a staff member entered the residents room to offer assistance after Resident #8 spoke with the front office and notified them of needing assistance. Interview on 04/26/21 at 11:52 A.M. with Elder Assistant #139 revealed she was not aware of Resident #8 needing assistance but would check on her right away. Review of a call light maintenance log dated 04/26/21, revealed Resident #8's call light was not properly functioning. Upon inspection, it was noted that Resident #8's call light pendent needed new batteries and after the batteries were changed it was properly working and alarming. Facility policy in regards to Call Lights, was requested and was not provided. 366430 Page 2 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure Resident #24 and Resident #32 were provided privacy during personal care. This affected two, (Resident #24, and #32) of the two residents observed for personal care. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 05/30/18 with diagnoses including dementia without behavioral disturbances, need for assistance with personal care, and muscle weakness. Review of Resident #24's plan of care dated 07/22/20 revealed the resident had impaired ability to perform or complete activities of daily living such as feeding, dressing, bathing, and toileting related to dementia unsteadiness on feet and need for assistance with personal care. Interventions included to encourage the resident to perform self care with activities of daily living. Review the the plan of care dated 07/22/20 revealed Resident #24 experienced bladder incontinence related to dementia, muscle weakness, and a history of urinary tract infections. Interventions included to clean peri-area with each incontinence episode, and check as required for incontinence episodes. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident experienced long and short term memory problems and had a severely impaired cognition for daily decision making ability. Resident #24 required extensive assistance from two staff members for bed mobility, transfers, dressing, and toilet use. Resident #24 was noted to be frequently incontinent of bowel and bladder. Observation on 05/03/21 at 2:42 P.M. revealed Elder Assistant #108 and Elder Assistant #139 entered Resident #24's room to complete incontinence care for Resident #24. Resident #24's bedroom door was closed but the resident window blind remained open. Elder Assistant #108 and Elder Assistant #139 proceeded to uncover Resident #24 and remove the incontinence brief to complete incontinence care. Resident #24's private area was observed to be completely exposed. Interview on 05/03/21 at 2:48 P.M. with Elder Assistant #139 confirmed Resident #24's window blind remained open while personal incontinence care was being completed. Elder Assistant #139 also confirmed Resident #24's room was located on the ground floor and her window was located next to an area of the building where new construction was going on and construction staff members were noted to walk past Resident #24's bedroom window throughout the day. Elder Assistant #108 and Elder Assistant #139 verified the window blind needed to be closed to provided Resident #24 with privacy. Review of the facility policy titled, Incontinence Care, (undated), revealed under Procedure 2., the facility staff should Drape elder for privacy. 2. Review of the medical record for Resident #32 revealed an admission date of 03/02/21, with diagnoses including bipolar disorder, current episode depressed with severe psychotic feature, catatonic disorder, and protein calorie malnutrition. 366430 Page 3 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #32's admission MDS 3.0 assessment dated [DATE], revealed resident experienced long and short term memory problems and had severely impaired cognitive skills for daily decision making ability. Resident #32 required extensive assistance from two staff members for bed mobility, transfer, dressing, and toilet use. Review of Resident #32's plan of care dated 03/15/21 revealed resident required a G-tube and interventions included checking the tube for placement, and applying a dry dressing daily and as needed. Review of Resident #32's physician orders for May, 2021 revealed and order for, triple antibiotic ointment, apply to Gastronomy tube (G-tube) site topically, two times a day for prevention. Cleanse the G-tube site with normal saline, apply the triple antibiotic ointment and cover with a split gauze. Observation on 05/03/21 at 1:28 P.M. revealed Licensed Practical Nurse (LPN) #105 entered Resident #32's room to complete a scheduled G-tube dressing change. After entering the residents room, hand hygiene and supplies were gathered. The procedure was explained to the resident and completed with no concerns. Resident #32's bedroom door and window blind was noted to remain open during this dressing change to Resident #32's abdomen. Interview on 05/03/21 at 1:32 P.M. with LPN #105 confirmed Resident #32's bedroom door and window blind remained open during the G-tube dressing change and they should have been closed to ensure resident privacy. Facility policy in regards to dressing changes or privacy was not provided when requested. 366430 Page 4 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide written notification to resident/resident representative and state ombudsman when Resident #16, Resident #43, and Resident #44 were discharged from the facility. This affected three (Residents #16, #43, and #44) of four residents reviewed for discharge. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. His diagnoses were chronic ischemic heart disease, atherosclerotic heart disease, pure hypercholesterolemia, blindness right eye category 3, anemia, acquire absence of right leg below knee, anxiety disorder, type II diabetes, hypertension, and schizophrenia. Resident #16's Minimum Data (MDS) assessment dated [DATE] revealed his Brief Interview for Mental Status (BIMS) score was 13, which indicated he was cognitively intact for decision making. Review of Resident #16 medical records revealed he was discharged to the hospital on [DATE] and 02/12/21 for medical issues that the facility could not manage. There was no documentation to support that the facility gave Resident #16 and the state ombudsman written notification of his discharge. Interview with Administrator on 05/03/21 at 12:26 P.M. confirmed the facility had no evidence to support that the facility notified the resident or the state ombudsman's office when he was discharged to the hospital. 2. Resident #43 was admitted to the facility on [DATE]. Her diagnoses were sepsis, major depressive disorder, hypertension, acute kidney failure, pneumonia, urinary tract infection, anxiety disorder, type II diabetes, osteoporosis, hyperlipidemia, and insomnia. Resident #43's MDS assessment dated [DATE] revealed her BIMS score was seven, which indicated she had a mild cognitive impairment. Review of Resident #43 medical records revealed he was discharged to the hospital on [DATE] for medical issues that the facility could not manage. There was no documentation to support that the facility gave Resident #43 representative and the state ombudsman written notification of her discharge. Interview with Administrator on 05/03/21 at 12:26 P.M. confirmed the facility had no evidence to support that the facility notified the resident's representative or the state ombudsman's office when he was discharged to the hospital. 3. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were altered mental status, disorientation, Alzheimer's disease, and dementia. Resident #44's MDS assessment dated dated 02/13/21 revealed her BIMS score was three, which indicated she had a severe cognitive impairment. Review of Resident #44 medical records revealed he was discharged to her home on [DATE]. There was 366430 Page 5 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0623 Level of Harm - Minimal harm or potential for actual harm no documentation to support that the facility gave Resident #44 representative and the state ombudsman written notification of her discharge. Interview with Administrator on 05/03/21 at 12:26 P.M. confirmed the facility had no evidence to support that the facility notified the resident's representative or the state ombudsman's office when he was discharged . Residents Affected - Few Review of facility Transfer/Discharge Policy and Procedure (dated 08/19/19), revealed the facility must notify the resident and resident representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood. They also must send a copy of the discharge notice in writing to the state ombudsman office and to the state department of health. 366430 Page 6 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide bed hold notification to Resident #16 and Resident #43 when discharged to the hospital. This affected two (Resident #16 and Resident #43) of two residents reviewed for hospital admissions. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. His diagnoses were chronic ischemic heart disease, atherosclerotic heart disease, pure hypercholesterolemia, blindness right eye category 3, anemia, acquire absence of right leg below knee, anxiety disorder, type II diabetes, hypertension, and schizophrenia. Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was 13, which indicated he was cognitively intact. Review of Resident #16 medical records revealed he was discharged to the hospital on [DATE] and 02/12/21 for medical issues that the facility could not manage. There was no documentation to support the facility provided a bed hold notification to him either time he was sent to the hospital. Interview with Administrator on 05/03/21 at 12:26 P.M. confirmed the facility had no evidence to support that the facility provided the bed hold notification to Resident #16 during the time that he was discharged to the hospital. 2. Resident #43 was admitted to the facility on [DATE]. Her diagnoses were sepsis, major depressive disorder, hypertension, acute kidney failure, pneumonia, urinary tract infection, anxiety disorder, type II diabetes, osteoporosis, hyperlipidemia, and insomnia. Resident #43's MDS assessment dated [DATE] revealed her BIMS score was seven, which indicated she had a mild cognitive impairment. Review of Resident #43 medical records revealed he was discharged to the hospital on [DATE] for medical issues that the facility could not manage. There was no documentation to support that the facility gave Resident #43 representative a bed hold notification form. Interview with Administrator on 05/03/21 at 12:26 P.M. confirmed the facility had no evidence to support that the facility provided the bed hold notification to Resident #43 representative during the time that she was discharged to the hospital. Review of facility Bed Hold Policy (dated 11/14/17), revealed all residents/elders and representatives are notified of the bed hold policy at the time of admission, prior to any transfer, therapeutic leave, and at the time of transfer. If the transfer is emergent, the resident/elder and representative must be notified within 24 hours. This bed hold policy applies to all residents/elders regardless of payer source. 366430 Page 7 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 provide/maintain an accurate Pre-admission Screening and Resident Review (PASRR) for Resident #16. This affected one (Resident #16) of two resident reviewed for PASRR. Residents Affected - Few Findings Include: Resident #16 was admitted to the facility on [DATE]. His diagnoses were chronic ischemic heart disease, atherosclerotic heart disease, pure hypercholesterolemia, blindness right eye category 3, anemia, acquire absence of right leg below knee, anxiety disorder, type II diabetes, hypertension, and schizophrenia. Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed his Brief Interview for Mental Status (BIMS) score was 13, which indicated he was cognitively intact. Review of Resident #16 medical records revealed he was admitted with the diagnoses of schizophrenia and anxiety disorder. When reviewing his PASRR application, under Section D (Indications of Serious Mental Illness), the question, Does the individual have a diagnosis of any of the mental disorders listed below was marked as, no. Options listed as mental illness diagnoses included schizophrenia and panic or other severe anxiety disorder. Resident #16 was treated with the following medications related to his schizophrenia and anxiety diagnoses: Divalproex Sodium 250 milligrams (mg) three times daily for anxiety, Trazodone 25 mg three times daily for anxiety, Risperdal 0.5 mg twice daily for schizophrenia, and Lorazepam 0.5 mg every eight hours as needed for anxiety. Interview with Business Office Coordinator (BOC) #137 and Quality of Life Coordinator (QOLC) #153 on 05/03/21 at 2:05 P.M. confirmed that if a resident has a mental health diagnosis that is identified on the PASRR application, they are to add it and send it to the state mental health authority. They also confirmed that if a resident has a PASRR application completed at the time of admission, they are to review the existing PASRR to determine it's accuracy. They confirmed Resident #16 had diagnoses of schizophrenia and anxiety (as well as medical treatments for them) and they were not listed on his current PASRR application. 366430 Page 8 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #16 was admitted to the facility on [DATE]. His diagnoses were chronic ischemic heart disease, atherosclerotic heart disease, pure hypercholesterolemia, blindness right eye category 3, anemia, acquire absence of right leg below knee, anxiety disorder, type II diabetes, hypertension, and schizophrenia. Resident #16's MDS assessment dated [DATE] revealed his Brief Interview for Mental Status (BIMS) score was 13, which indicated he was cognitively intact. Residents Affected - Few Review of Resident #16 medical records revealed he did not have an activities assessment to determine what activities he preferred and did not prefer. Also, he did not have an activities care plan to give interventions/direction to staff on what to offer him as an activity. Observations on 04/27/21, 04/29/21, and 05/03/21 revealed no group activities were offered in the facility. Also, there were no board games or individual activities found within his room. Also, he was found to be sleeping quite often, with no one visiting his room. The excessive sleeping was not determined to be any type of medical issue. Review of the facility activity calendar for February 2021, March 2021, and April 2021, revealed one activity listed for each day. The activity for 04/26/21 was Pretzel Day', 04/27/21 was Nail Care, 04/28/21 was Bingo, and 04/29/21 was one on one activities. None of theses scheduled activities were observed to be completed. An interview was attempted with Resident #16 on 04/29/21 at approximately 10:35 A.M., but he did not want to be interviewed. Interview with Administrator on 05/04/21 at 8:35 A.M. confirmed that if there were no activity assessments, care plans, or logs/documentation in the electronic records, then it probably did not exist. Based on observation, medical record review, and staff and resident interview, the facility failed to properly assess, care plan, and provide activities of preference for Resident #16, Resident #28, and Resident #142. This affected three (Resident #16, #28, and #142) of the three residents reviewed for activities. Findings include: 1. Review of medical record review for Resident #28 revealed an initial admission date of 01/30/20 and a re-admit date of 03/25/21. Diagnoses included malignant neoplasm of skin of breast, major depressive disorder recurrent, and anemia. Review of Resident #28's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had an intact cognition for decision making. One of the activities noted to be important to Resident #28 was to do things with groups of people. Review of Resident #28's activity note dated 01/31/21 revealed the resident was here for a short term stay and an activity screening assessment was completed directly. 366430 Page 9 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0679 Level of Harm - Minimal harm or potential for actual harm Review of Resident #28's plan of care dated 04/06/21, revealed there was no care plan related to activities or preferences. Review of Resident #28's activity participation log for April, 2021, revealed one on one activities were completed every day. Residents Affected - Few Interview on 04/27/21 at 11:30 A.M. with Resident #28 revealed the facility had not been offering actives the last few months. Resident #28 stated she enjoyed going to group activities and playing games like Bingo but has not been able to do this. Resident #28 denied being offered activities to complete independently or having a staff member complete one on one activities with her. Observation between 04/26/21 through 04/29/21 of the facility revealed no active group activities being completed nor was an activity cart observed being taking to residents for choice of independent activity. Review of the facility activity calendar for February 2021, March 2021, and April 2021, revealed one activity listed for each day. The activity for 04/26/21 was Pretzel Day', 04/27/21 was Nail Care, 04/28/21 was Bingo, and 04/29/21 was one on one activities. None of theses scheduled activities were observed to be completed. Interview with Administrator on 05/04/21 at 8:35 A.M. confirmed that if there were no activity assessments, care plans, or logs/documentation in the electronic records, then it probably did not exist. 2. Review of the medical record for Resident #142 revealed an admission date of 04/10/21. Diagnosis included benign neoplasm of cerebral meninges, major depressive disorder recurrent, and suicidal ideations. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating an moderately impaired cognition for daily decision making ability. Resident #142 required extensive assistance from two staff members for bed mobility, transfers, dressing, and toilet use. Review of Resident #142's plan of care revealed no care plan related to activity and preferences. Review of Resident #142's activity participation log for April, 2021, revealed one on one activities completed every day. Interview on 04/27/21 at 11:45 A.M. with Resident #142 revealed she has been at this facility for about 3 weeks now and has not observed any activities taking place nor had she been offered to participate in any activities. Resident #142 states she would like to do something other that watch the television in her room all day. Observation between 04/26/21 through 04/29/21 of the facility revealed no active group activities being completed nor was an activity cart observed being taking to residents for choice of independent activity. Review of the facility activity calendar for February 2021, March 2021, and April 2021, revealed one activity listed for each day. The activity for 04/26/21 was Pretzel Day', 04/27/21 was Nail Care, 366430 Page 10 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0679 Level of Harm - Minimal harm or potential for actual harm 04/28/21 was Bingo, and 04/29/21 was one on one activities. None of theses scheduled activities were observed to be completed. Interview with Administrator on 05/04/21 at 8:35 A.M. confirmed that if there were no activity assessments, care plans, or logs/documentation in the electronic records, then it probably did not exist. Residents Affected - Few 366430 Page 11 of 12 366430 05/04/2021 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on facility record review and staff interview, the facility failed to provide evidence that the facility conducted a quarterly quality assessment and assurance (QAA) meeting at least once per quarter. This had the potential to affect 43 of 43 residents in the facility. Residents Affected - Many Findings Include: Review of facility Quality Assurance meeting signature sheets (for meeting attendance) revealed the facility only had evidence that meetings were held on 03/24/21 and 12/30/20 in the last 12 months. There was no evidence that a meeting was held in 2nd and 3rd quarter of 2020. Interview with Administrator on 05/04/21 at 8:32 A.M. confirmed they could not find evidence that the meetings were held. 366430 Page 12 of 12