Health inspection·July 25, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the physician was notified of a weight gains as ordered. This affected two (Resident #26 and #62) out of six residents reviewed for notification of change. The facility census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed Resident #26 was admitted to the facility on [DATE]. Her diagnoses included kidney failure, diastolic (congestive) heart failure, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderate cognitive impairment. Review of the care plan for Resident #26 revealed Resident #26 had potential for or alteration in cardiac output/arrhythmia/cardiorespiratory distress related to her coronary artery disease, hyperlipidemia, hypertension, congestive heart failure, and peripheral vascular disease. The interventions included monitoring vital signs and weights as ordered. Review of the physician orders revealed Resident #26 had an order dated 04/24/22, which was discontinued on 07/20/22, for daily weights. The order indicated staff were to notify the physician if Resident #26's weight gain was greater than five pounds in three days. Resident #26's weight was to be obtained in the morning. Review of Resident #26's weight records revealed Resident #26 weighed 167.5 pounds on 06/27/22 and weighed 176.6 pounds on 06/30/22 which reflected a 9.1 pound weight gain from 06/27/22 to 06/30/22. Further review of the weight records revealed Resident #26 weighed 167.4 pounds on 07/07/22 and weighed 177 pounds on 07/09/22 which reflected a 9.6 pound weight gain from 07/07/22 to 07/09/22. Interview with the Director of Nursing (DON) on 07/21/22 at 2:31 P.M. verified the physician was not notified of Resident #26's weight gains on 06/30/22 (9.1 pounds) and 07/09/22 (9.6 pounds). Review of the policy titled Procedure for Weight Loss/Gain Monitoring, reviewed 11/2021, revealed weight changes were monitored by nursing and the dietitian or diet tech. It indicated the resident, the resident's physician and the resident's sponsor/responsible party are notified of significant weight change. Page 1 of 6 366437 366437 07/25/2022 Arlington Pointe 4900 Hendrickson Road Middletown, OH 45044

F 0580 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #62 revealed an admission date of 10/02/21. Diagnoses included acute kidney failure, type two diabetes mellitus, hyperlipidemia, atrial flutter. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #62 dated 07/01/22 revealed the resident had impaired cognition. Residents Affected - Few Review of the plan of care for Resident #62 dated 10/06/21 revealed the resident had the potential for an alteration in cardiac function related to hypertension and atrial fibrillation. Interventions included administer medications as ordered, assess for edema, and monitor vital signs and weights as ordered. Review of the active physician orders for Resident #62 revealed an order with a start date of 10/27/21 for daily weights. The order stated to obtain daily weights and call the doctor with a weight gain of three pounds in one day or more than five pounds in one week. Review of the medical record for Resident #62 revealed no weights were obtained on 07/14/22 and 07/15/22. The weight recorded on 07/13/22 was 149.4 pounds (lbs.) and on 07/16/22 was 159 lbs. Resident #62 experienced a weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Review of the progress notes for Resident #62 revealed there was no evidence the facility notified the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Interview on 07/21/22 at 9:05 A.M. with the Director of Nursing (DON) confirmed no daily weights were obtained on 07/14/22 and 07/15/22 for Resident #62. The DON also confirmed the order for daily weights was current and that the order specified to notify the doctor with a three-pound weight gain in a day or five pounds in a week. The DON also confirmed there was no notification to the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. 366437 Page 2 of 6 366437 07/25/2022 Arlington Pointe 4900 Hendrickson Road Middletown, OH 45044

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Based on medical record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASSAR) and notify the state mental health authority for residents with new mental health diagnoses. This affected two residents (#35 and #83) out of three residents reviewed for PASSAR's. The facility census was 92. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 02/18/19. Diagnoses included dementia with behaviors, shortness of breath, chest pain, anxiety disorder, dysphagia, and psychotic disorder (08/21/20). Review of the PASSAR for Resident #35 dated 02/18/19, revealed psychotic disorder was not included in the assessment. Review of the medical record for Resident #35 revealed the diagnosis of psychotic disorder was added on 08/21/20. Review of the medical record for Resident #35 revealed the facility did not complete a significant change PASSAR for Resident #35 following Resident #35's new diagnosis of psychotic disorder on 08/21/20. Interview on 07/19/22 at 2:47 P.M. with Admissions Director (AD) #37 confirmed no significant change PASSAR was completed for Resident #35 after the new diagnosis of psychotic disorder on 08/21/20. 2. Review of the medical record for Resident #83 revealed an admission date of 08/30/19. Diagnoses included hemiplegia, hemiparesis, sepsis, type two diabetes mellitus, obesity, pneumonia, dysphagia, major depressive disorder (01/16/20), and schizoaffective disorder (12/03/19). Review of the PASSAR for Resident #83 dated 08/29/19, revealed no psychiatric diagnoses were selected on the assessment. Review of the medical record for Resident #83 revealed a diagnosis of schizoaffective disorder was added on 12/03/19 and a diagnosis of major depressive disorder was added on 01/16/20. Review of the medical record for Resident #83 revealed the facility did not complete a significant change PASSAR for Resident #83 following Resident #83's new diagnosis of schizoaffective disorder on 12/03/19 and/or new diagnosis of major depressive disorder on 01/16/20. Interview on 07/19/22 at 2:47 P.M. with Admissions Director #37 confirmed no significant change PASSAR was completed for Resident #83 after Resident #83 had a new diagnosis of schizoaffective disorder on 12/03/19 and new diagnosis of major depressive disorder on 01/16/20. 366437 Page 3 of 6 366437 07/25/2022 Arlington Pointe 4900 Hendrickson Road Middletown, OH 45044

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure daily weights were completed as ordered. Additionally, the facility failed to timely implement interventions and reassess a resident with severe weight loss. This affected two (Resident #62 and #83) out of three residents reviewed for nutrition. The facility census was 92. Residents Affected - Few 1. Review of the medical record for Resident #62 revealed an admission date of 10/02/21. Diagnoses included acute kidney failure, type two diabetes mellitus, hyperlipidemia, atrial flutter. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #62 dated 07/01/22 revealed the resident had impaired cognition. Review of the plan of care for Resident #62 dated 10/06/21 revealed the resident had the potential for an alteration in cardiac function related to hypertension and atrial fibrillation. Interventions included administer medications as ordered, assess for edema, and monitor vital signs and weights as ordered. Review of the active physician orders for Resident #62 revealed an order with a start date of 10/27/21 for daily weights. The order stated to obtain daily weights and call the doctor with a weight gain of three pounds in one day or more than five pounds in one week. Review of the medical record for Resident #62 revealed no weights were obtained on 07/14/22 and 07/15/22. The weight recorded on 07/13/22 was 149.4 pounds (lbs.) and on 07/16/22 was 159 lbs. Resident #62 experienced a weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Review of the progress notes for Resident #62 revealed no documented reason regarding why Resident #62's weight was not obtained on 07/14/22 and 07/15/22. There was no evidence the facility notified the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. Resident #62 did not experience any distress or negative outcome related to the failure to weigh the resident daily and report the weights. Review of the medication administration record (MAR) for Resident #62 revealed the order for daily weights was not signed off as completed on 07/14/22 and 07/15/22. Interview on 07/21/22 at 9:05 A.M. with the Director of Nursing (DON) confirmed no daily weights were obtained on 07/14/22 and 07/15/22 for Resident #62. The DON also confirmed the order for daily weights was current and that the order specified to notify the doctor with a three-pound weight gain in a day or five pounds in a week. The DON also confirmed there was no notification to the physician regarding Resident #62's weight gain of 9.6 lbs. from 07/13/22 to 07/16/22. 2. Review of the medical record for Resident #83 revealed an admission date of 08/30/19. Diagnoses included hemiplegia, hemiparesis, sepsis, type two diabetes mellitus, obesity, and dysphagia. Review of the quarterly Minimum Data Set assessment for Resident #83 dated 07/05/22 revealed the resident had an impaired cognition. No significant weight loss or gain was noted for Resident #83 on the assessment. Review of the plan of care for Resident #83 dated 01/27/22 revealed Resident #83 was at risk for 366437 Page 4 of 6 366437 07/25/2022 Arlington Pointe 4900 Hendrickson Road Middletown, OH 45044

F 0692 Level of Harm - Minimal harm or potential for actual harm potential nutritional problems related to therapeutic diet. Interventions included providing diet as ordered, monitoring weight monthly and as needed, and providing and serving supplements as ordered. Review of the medical record for Resident #83 revealed a weight on 06/08/22 of 210 lbs. A weight of 194.3 lbs. was obtained on 07/11/22. Residents Affected - Few Review of the physician orders for Resident #83 from 07/11/22 to 07/19/22 revealed no orders to monitor Resident #83's weight more frequently or to obtain a reweigh for Resident #83. Review of the medical record for Resident #83 revealed a weight of 199 lbs. was obtained on 07/19/22. Review of the dietary notes for Resident #83 dated 07/20/22 revealed Resident #83 would be started on a nutritional supplement twice daily to help with weight gain. Review of the medical record for Resident #83 revealed no nutritional interventions were implemented after Resident #83 was found to have experienced a severe weight loss on 07/11/22 until 07/20/22 when Resident #83 was started on a nutritional supplement twice daily to help with weight gain. Interview on 07/19/22 at 4:20 P.M. with Registered Dietitian (RD) #121 confirmed no reweigh had been completed on Resident #83 after identifying that he experienced a severe 15.7 lb. (7.47 percent) weight loss from 06/08/22 to 07/11/22. RD #121 stated that she would have typically recommended Resident #83 be reweighed to determine the accuracy of the weight and had no explanation as to why Resident #83 was not reweighed. RD #121 also stated that she had not made the recommendation or requested an order be put in to reweigh Resident #83. Review of the facility policy titled Procedure for Weight loss/gain monitoring dated 11/2021, revealed the facility failed to implement their policy. The dietician or dietician technician, in coordination with the interdisciplinary team evaluate the weight change and make appropriate recommendations for unplanned weight changes as necessary to meet resident's goals for care. 366437 Page 5 of 6 366437 07/25/2022 Arlington Pointe 4900 Hendrickson Road Middletown, OH 45044

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, staff interviews, review of a facility policy, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore the proper personal protective equipment when entering the room of a resident who was in quarantine for COVID-19. This affected one (Resident #188) and had the potential to to affect all 92 residents in the facility. The facility census was 92. Residents Affected - Many Findings include: Review of Resident #188's medical record revealed an admission date of 07/12/22. Diagnoses included heart failure, kidney disease, and high blood pressure. Review of Resident #188's admission assessment, dated 07/19/22, revealed Resident #188 was not cognitively impaired and required assistance of one staff with care. Resident #188 was placed in quarantine (transmission based precautions) due to a recent hospital stay and possible exposure to COVID-19. Observation on 07/18/22 at 10:00 A.M. revealed Housekeeper #53 entered Resident #188's room while wearing a surgical mask which was pulled below her nose. Housekeeper #53 went in and out of Resident #188's room twice. Observation on 07/18/22 at 12:14 P.M. revealed State Tested Nursing Assistant (STNA) #16 was delivering meal trays and went in Resident #188's room while only wearing a surgical mask and without donning an isolation gown. Interview with Housekeeper #53 on 07/18/22 at 10:05 A.M. verified Resident #188 was in quarantine and she did not wear the correct personal protective equipment (PPE) while in Resident #188's room. Housekeeper #53 verified her mask was not in the correct position. Interview on 07/18/22 at 12:20 P.M., with STNA #16 verified he/she was not wearing proper PPE while entering Resident #188's room. Review of the facility policy titled COVID-19, revised 02/2022, revealed residents in quarantine require transmission based precautions and should be cared for by staff wearing full PPE. Review of the CDC guidelines, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/02/22, revealed healthcare personnel caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). 366437 Page 6 of 6