Health inspection·October 10, 2024

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, medical record review and interviews, the facility failed to ensure Resident #31's call light was answered in a timely manner. This affected one resident (#31) of seven sampled residents. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of [DATE] with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required substantial/maximal assistance with toileting, bathing, dressing, bed mobility, partial/moderate assistance with personal hygiene and dependent for transfers. The assessment indicated the resident was occasionally incontinent of bladder and always continent of bowel. On [DATE] at 9:35 A.M., observation of Resident #31's call light revealed the light was activated upon entry to the 500 unit. Stated Tested Nursing Assistant (STNA) #101 exited another resident's room at 9:36 A.M. and made no effort to answer Resident #31's activated call light and left the 500 unit. Licensed Practical Nurse (LPN) #155 exited another resident's room at 9:38 A.M. and went to the 400/500 units nurses station were various staff were observed talking making no attempt to answer the call light. LPN #155 was notified of the need of assistance in the resident's room by her family member due to having a scheduled appointment. LPN #155 revealed the assigned STNA was with another resident. The LPN was informed the STNA finished with another resident at 9:36 A.M. and left the unit. The LPN revealed when two residents have appointments one had to be second. Again the LPN was informed the STNA finished with the other resident and left the unit at 9:36 A.M. and the resident's family member was attempting to get the resident ready for the scheduled appointment and requested assistance. The LPN stated, well and walked away and made no attempt to answer the activated call light. On [DATE] at 9:46 A.M. interview with LPN #209 revealed she would answer Resident #31's call light that had been activated for more than 10 minutes with staff making no attempt to answer the call Page 1 of 20 366462 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0558 light. LPN #209 revealed she would educate staff on answering call lights timely. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 1:10 P.M., interview with the resident's family member revealed she activated the resident's call light at 9:25 A.M. when she attempted to apply the resident's incontinence brief but had difficulty. She revealed the resident had a scheduled appointment and staff had not readied her for the appointment. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00158259. 366462 Page 2 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations of photographs, interviews and facility policy review, the facility failed to report an injury of unknown origin for one resident (#51) with facial bruising who was dependent on staff to the required state agency. This affected one (Resident #51) of one resident reviewed for injury of unknown origin. The facility census was 72. Findings Include: Review of the medical record for Resident #51 revealed an initial admission date of 03/12/20 with the diagnoses including but not limited to cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, stage IV pressure ulcer left ankle, Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated falls, osteoarthritis and dysphagia. Review of the plan of care dated 07/25/23 revealed the resident had a potential for skin tear and 09/14/24 monitor bilateral bruising to mouth. Interventions included monitor bruising to mouth daily until healed. Review of the resident's state optional Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. The resident required extensive assistance of one for eating. Review of the staff statement by Licensed Practical Nurse (LPN) #241 revealed she was walking on the 200 unit and noticed Resident #51 had discoloration to his jaw. The LPN documented a head to toe assessment was completed with no pain or discomfort observed. Review of the staff statement by State Tested Nursing Assistant (STNA) #237 dated 09/13/24 revealed she was asked by another unknown STNA to assist with transferring the resident into his Broda chair for breakfast. The STNA verified she had observed the bruising to the resident's jaw. Review of the staff statement by STNA #190 dated 09/13/24 revealed she had noticed the mark on the resident's face during the breakfast meal but had not reported the mark to anyone because it did not look like a bruise or anything hurtful. Review of the staff statement by Registered Nurse (RN) #201 revealed she had not noticed any bruising however LPN #241 alerted her of the bruising and to complete and incident report. Review of the progress note dated 09/14/24 at 2:53 P.M. revealed LPN #241 was passing by while the resident was sitting in a recliner in the 200 unit living room. LPN #241 noticed the resident had bruising to each side of the resident's lower jaw. An assessment was completed and the bruise to the right lower jaw measured 4.0 cm by 3.0 cm and the bruise on the left side of the jaw measured 3.0 cm by 2.0 cm. The entry documented the bruise to the right side of the jaw was darker than the bruise to the left side of the jaw, however no description of the bruises was documented in the entry. 366462 Page 3 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of the facility's investigation revealed skin sweeps for those residents residing on the 200 unit were not conducted until 09/16/24. Review of the facility investigation revealed skin sweeps for those like residents were not completed until 09/17/24. Residents Affected - Few Review of the progress note dated 09/17/24 at 11:00 A.M. revealed the Director of Nursing (DON) met with the resident's wife and hospice nurse to follow up on the resident's recent bruising and other concerns. The resident's bruising was discussed including the facility's investigation which the facility determined the approximate time to be around lunch on 09/13/24. The facility determined the probable cause was someone was holding the resident's mouth to encourage eating as the resident had a history of pocketing food and being difficult to feed. The facility had planned to re-educate staff, the wife and friends who feed the resident. Review of the resident's physician orders for September 2024 identified an order dated 09/17/24 monitor bruising to bilateral mouth daily until healed. On 10/02/24 at 12:24 P.M., interview with Resident #51's family member revealed she visited her husband every other day and on 09/14/24 when she arrived to visit her husband the bruising to both sides of her jaw were bruised. She revealed she photographed the bruising. Observation of two photographs in the resident's family member's personal phone revealed two dark purple bruises on each side of the resident's chin. On 10/03/24 at 11:30 A.M., interview with the Director of Nursing (DON) verified the facility had not notified the required state agency of the injury of unknown origin. Review of the facility policy titled, Abuse, last updated on 05/24/23 revealed residents have the right to be free from neglect, exploitation, mistreatment and misappropriation of resident property. The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property and crimes are reported immediately to the Administrator and reported to the state survey agency immediately but not later than tow hours after the allegation is made of the allegation involves abuse or results in serious bodily injury and to other officials. This deficiency represents non-compliance investigated under Complaint Number OH00157930. 366462 Page 4 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0610 Respond appropriately to all alleged violations. 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, observations of photographs, interviews and facility policy review, the facility failed to timely investigate an injury of unknown origin for one resident (#51) with facial bruising who was dependent on staff. This affected one (Resident #51) of one resident reviewed for injury of unknown origin. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #51 revealed an initial admission date of 03/12/20 with the diagnoses including but not limited to cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, stage IV pressure ulcer left ankle, Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated falls, osteoarthritis and dysphagia. Review of the plan of care dated 07/25/23 revealed the resident had a potential for skin tear and 09/14/24 monitor bilateral bruising to mouth. Interventions included monitor bruising to mouth daily until healed. Review of the resident's state optional Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. The resident required extensive assistance of one for eating. Review of the staff statement by Licensed Practical Nurse (LPN) #241 revealed she was walking on the 200 unit and noticed Resident #51 had discoloration to his jaw. The LPN documented a head to toe assessment was completed with no pain or discomfort observed. Review of the staff statement by State Tested Nursing Assistant (STNA) #237 dated 09/13/24 revealed she was asked by another unknown STNA to assist with transferring the resident into his Broda chair for breakfast. The STNA verified she had observed the bruising to the resident's jaw. Review of the staff statement by STNA #190 dated 09/13/24 revealed she had noticed the mark on the resident's face during the breakfast meal but had not reported the mark to anyone because it did not look like a bruise or anything hurtful. Review of the staff statement by Registered Nurse (RN) #201 revealed she had not noticed any bruising however LPN #241 alerted her of the bruising and to complete and incident report. Review of the progress note dated 09/14/24 at 2:53 P.M. revealed LPN #241 was passing by while the resident was sitting in a recliner in the 200 unit living room. LPN #241 noticed the resident had bruising to each side of the resident's lower jaw. An assessment was completed and the bruise to the right lower jaw measured 4.0 cm by 3.0 cm and the bruise on the left side of the jaw measured 3.0 cm by 2.0 cm. The entry documented the bruise to the right side of the jaw was darker than the bruise to the left side of the jaw, however no description of the bruises was documented in the entry. Review of the facility's investigation revealed skin sweeps for those residents residing on the 200 366462 Page 5 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0610 unit were not conducted until 09/16/24. Level of Harm - Minimal harm or potential for actual harm Review of the facility investigation revealed skin sweeps for those like residents were not completed until 09/17/24. Residents Affected - Few Review of the progress note dated 09/17/24 at 11:00 A.M. revealed the Director of Nursing (DON) met with the resident's wife and hospice nurse to follow up on the resident's recent bruising and other concerns. The resident's bruising was discussed including the facility's investigation which the facility determined the approximate time to be around lunch on 09/13/24. The facility determined the probable cause was someone was holding the resident's mouth to encourage eating as the resident had a history of pocketing food and being difficult to feed. The facility had planned to re-educate staff, the wife and friends who feed the resident. Review of the resident's physician orders for September 2024 identified an order dated 09/17/24 monitor bruising to bilateral mouth daily until healed. On 10/02/24 at 12:24 P.M., interview with Resident #51's family member revealed she visited her husband every other day and on 09/14/24 when she arrived to visit her husband the bruising to both sides of her jaw were bruised. She revealed she photographed the bruising. Observation of two photographs in the resident's family member's personal phone revealed two dark purple bruises on each side of the resident's chin. On 10/03/24 at 11:30 A.M., interview with the Director of Nursing (DON) revealed an investigation of the facial bruising to Resident #51's jaw when management was made aware on 09/16/24. The DON verified the investigation was not timely. Review of the facility policy titled, Abuse, last updated on 05/24/23 revealed residents have the right to be free from neglect, exploitation, mistreatment and misappropriation of resident property. The key to investigating abuse allegation is an environment that facilitates the reporting of such allegations. Once reported the center conducts a timely, thorough and objective investigation of any allegation of abuse. This deficiency represents non-compliance investigated under Complaint Number OH00157930. 366462 Page 6 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, hospice staff interview, review of hospice visits notes and review of facility policy, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to timely identify, assess and implement treatment for Resident #51 related to a pressure ulcer to the left lateral foot. Residents Affected - Few Actual harm occurred on 08/09/24 when Resident #51, who was cognitively impaired and dependent on staff for activity of daily living care was first identified by the facility to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left lateral foot. Prior to 08/09/24 hospice staff had identified this pressure ulcer, however the facility failed to identify the unstageable pressure ulcer prior to 08/09/24, failed to ensure on-going assessments and monitoring of the ulcer were completed and failed to ensure the ulcer was properly treated to prevent deterioration. This affected one resident (#51) of three residents reviewed for skin breakdown. The facility census was 72. Findings Include: Review of the medical record for Resident #51 revealed an initial admission date of 03/12/20 with current diagnoses including cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, pressure ulcer left ankle (added on 08/03/24), Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated falls, osteoarthritis and dysphagia. Review of the resident's physician orders identified an order dated 03/15/23 for a skin evaluation to be completed weekly. Check skin for open areas, bruises, abrasions, DTI, and incisions. Review of the medical record revealed the resident was admitted to hospice services on 06/01/23 for the terminal diagnosis of Parkinson's disease with a life expectancy of six months or less if the disease runs its normal course. Review of the care plan dated 04/06/23 revealed the resident was at risk for pressure injury formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, incontinence of bowel and bladder, the resident needing assistance with incontinence care, turning/repositioning and the presence of a pressure injury to the sacrum. Interventions included treatment per physician orders, barrier cream to buttocks after every incontinent episode, bilateral mobility bars to aide with turning and mobility in bed, Braden scale to be completed per facility policy, consult wound team as needed, encourage and assist as needed to turn/reposition per policy, use assistive devices as needed, encourage intake of 75 to 100% of diet and fluids daily. Dietician to assess dietary needs quarterly and with significant changes, encourage resident to float heels and/or wear heel boots, labs as ordered, report abnormal results to physician, low air loss mattress on bed, monitor skin daily during care for redness, excoriation or breakdown, pressure reduction cushion to broad chair, preventative skin care post incontinence care daily, as needed and skin evaluation 366462 Page 7 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 weekly and on 08/13/24 the facility implemented the use of a moon boot to the left foot at all times, remove for skin integrity checks every shift. Level of Harm - Actual harm Residents Affected - Few Review of the resident's Braden scale dated 02/05/24 revealed a score of 11 indicating the resident was at high risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. The assessment indicated the resident was at risk for skin breakdown and had one unstageable pressure ulcer not present on admission. The facility implemented pressure reducing device to bed/chair, pressure ulcer/injury care, application of nonsurgical dressings other than to feet and application of ointments/medications other than to feet. Record review revealed this pressure ulcer was to the resident's sacrum. A second State optional MDS assessment also dated 11/16/23 revealed the resident had a severe cognitive deficit and resident required extensive assistance from two staff for bed mobility, transfers and toileting. Review of a hospice wound note revealed on 02/06/24 the Hospice Registered Nurse (HRN) #295 identified Resident #51 had an unstageable deep tissue injury (DTI) (DTI is defined as a purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) to the left lateral foot measuring 2.5 centimeters (cm) by 2.5 cm by 0.5 cm. There were no additional notes from hospice on this date related to the why the ulcer developed. Review of the resident's medical record revealed no documented evidence the facility had identified or addressed the unstageable DTI development, implemented any interventions to prevent the worsening of the DTI or updated the resident's plan of care to reflect the development of the DTI. Review of a hospice wound note revealed on 02/12/24 the unstageable DTI to the left lateral foot measured 1.0 cm by 0.5 cm. The wound was described as square with less than 25% white necrotic tissue and 75 to 100% granulation tissue. Review of the resident's physician orders revealed no treatment was implemented for the DTI pressure ulcer/injury until 02/12/24 (six days after hospice staff first identified the ulcer) when an order was obtained to cleanse with soap and water or wound cleanser, pat dry and apply Allevyn dressing every shift for wound care. The order indicated the facility floor nurse was to complete wound care as needed if the dressing became heavily soiled. The order was discontinued on 02/14/24. On 02/16/24 a new order was noted to cleanse the left lateral foot with soap and water or wound cleanser, pat dry, apply Allevyn dressing every Monday and Friday for wound care. The order indicated hospice would provide all supplies and wound care and the facility floor nurse may complete (dressing change) as needed if heavily soiled. Review of the hospice wound note revealed on 02/19/24 the DTI to the left lateral foot measured 1.0 cm by 1.0 cm and described as round with 100% epithelialization. Review of the hospice wound note revealed on 02/26/24 the DTI to the left lateral foot measured 1.5 cm by 2.0 cm and remained round with 100% epithelialization. Review of the hospice wound note revealed on 03/04/24 the DTI to the left lateral foot measured 1.0 366462 Page 8 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 cm by 1.0 cm and remained round with 100% epithelialization. Level of Harm - Actual harm Review of the hospice wound note revealed the next comprehensive assessment of the DTI to the left lateral foot was completed on 03/22/24 and the ulcer measured 1.0 cm by 0.5 cm and was described as 75 to less than 100% necrotic tissue with distinct edges. Residents Affected - Few Review of the hospice wound record report revealed the next comprehensive assessment was completed on 04/22/24 (a month later). The DTI to the left lateral foot measured 0.5 cm by 0.5 cm. The wound was described as round. The hospice nurse implemented a treatment to cleanse the wound to the left lateral foot with soap and water or normal saline (NS), pat dry and apply a small Allevyn to pad and protect every Monday and Friday per the hospice nurse. Review of physician's orders dated 04/23/24 revealed an order for Enhanced Barrier Precautions every shift related to the resident's pressure ulcer. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 05/31/24 (over 30 days later) and the ulcer measured 0.5 cm by 0.5 cm and was described as being round. The same treatment continued, including the facility were to change the dressing as needed for dislodgement or soiled. Review of the resident's physician orders revealed the treatment order that was implemented on 02/16/24 to resident's left lateral foot was discontinued on 06/05/24. Review of the corresponding June 2024 Treatment Medication Record (TAR) also revealed the facility discontinued the treatment to the left lateral foot on 06/05/24. Record review revealed no facility assessments or progress notes from 02/2024 through 06/05/24 related to the resident's left lateral foot pressure ulcer. Review of a hospice wound record report revealed an assessment for the DTI to the left lateral foot was completed on 06/14/24 and the ulcer now measured 1.4 cm by 1.5 cm. The wound was described as round with 75 to 100% yellow slough. Despite the presence of yellow slough tissue, it appeared the treatment order that had been discontinued on 06/05/24 continued to be provided at this time. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 06/21/24 and the ulcer measured 0.5 cm by 1.5 cm. The wound was described with 26 to 50% white necrotic tissue. No changes were made to the resident's treatment. Review of physician's orders revealed an order dated 07/25/24 for house liquid protein 30 milliliters (ml) three times a day for wound healing. There was no additional information as to why this nutritional supplement was not added until 07/25/24 when the pressure ulcer was first identified in February 2024. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 08/02/24 (over 30 days from the previous assessment completed on 06/21/24). The ulcer was assessed to measure 2.0 cm by 1.5 cm by 0.5 cm. The wound was described as round with 50 to 75% white necrotic tissue with purulent drainage. Review of the hospice wound record report revealed the next assessment of the DTI to the left lateral foot was completed on 08/05/24 with the ulcer measuring 1.0 cm by 0.5 cm by 0.2 cm with 75 to 366462 Page 9 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 100% yellow necrotic tissue. Level of Harm - Actual harm Record review revealed no facility assessments or progress notes from 06/06/24 through 08/05/24 related to the resident's left lateral foot pressure ulcer. Residents Affected - Few A facility incident report dated 08/09/24 at 11:47 A.M. revealed Resident #51 was found to have a new pressure ulcer to the left lateral foot during a skin assessment. The facility implemented a treatment to cleanse with NS, apply calcium alginate and cover with boarder dressing. Record review revealed the facility also implemented protective boots at this time. Review of the progress note dated 08/09/24 at 11:55 A.M. revealed during skin assessment a new area was found, the Nurse Practitioner (NP), hospice and family were notified of the new area. The resident was referred to for wound care and a new order to cleanse with normal saline, apply calcium alginate and cover with foam border dressing was implemented. Although this area was consistent with the ulcer being treated by hospice, since February 2024, the first identification of the ulcer by the facility did not occur until 08/09/24 when the facility assessed the resident to have an unstageable pressure ulcer to the left lateral ankle. Review of the medical record revealed no documented evidence the facility comprehensively assessed the unstageable pressure ulcer to the resident's left lateral foot including measurements, description of the wound and exudate when found on 08/09/24 Review of a hospice wound record report revealed the next assessment of the DTI to the left lateral foot was completed on 08/12/24 measuring 1.0 cm by 2.0 cm with 75 to 100% yellow necrotic tissue, although the facility was classifying the DTI as an unstageable pressure ulcer on 08/09/24. Record review revealed the facility first weekly skin and wound evaluation was completed on 08/13/24 (four days after facility staff noted the ulcer) and revealed the resident had an unstageable pressure ulcer to the left lateral foot measuring 1.6 cm by 1.3 cm. The wound was described as having 100% slough with a moderate amount of serous exudate. The edges were described as non-attached. The facility documented the new area was found when doing skin assessment. The facility continued the 08/09/24 treatment to cleanse with normal saline (NS), apply calcium alginate and foam border dressing daily for wound care. Review of a physician order dated 08/13/24 revealed an order for a moon boot to the left foot at all times, remove for skin integrity check every shift. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the mood and behavior revealed the resident displayed physical behaviors directed towards others, however the resident did not reject care. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer that was not present on admission (ulcer to the coccyx) and one unstageable pressure ulcer that was not present on admission (to the left lateral foot). The assessment indicated the resident also had an infection to the foot and skin tears. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings other than to feet, 366462 Page 10 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 application of ointments/medications other than to feet and application of dressings to feet. Level of Harm - Actual harm Record review revealed beginning on 08/14/24 facility staff completed wound assessments which included the following: Residents Affected - Few A facility weekly skin and wound evaluation dated 08/14/24 revealed the unstageable pressure ulcer to the left lateral foot measured 1.5 cm by 1.2 cm by 0.2 cm. The wound was described as 100% slough with a moderate amount of serous exudate. The edges were attached and appeared as flush with wound bed or a sloping edge. The wound was new, and the wound physician made the initial visit and implemented the treatment to cleanse with normal saline (NS), pat dry, apply calcium alginate and foam border dressing. A facility weekly skin and wound evaluation dated 08/21/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.3 cm by 0.7 cm by 0.2 cm. The wound was described as having 40% slough and 50% granulation tissue with a moderate amount of serous exudate. The assessment had no documentation of the edges. The facility determined the wound had improved. The facility documented a Curette was used to surgically excise devitalized tissue including slough, biofilm and nonviable muscle level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40 percent to zero percent. Hemostasis was achieved and clean dressing was applied. The wound consisted of 40% slough, 50% granulation tissue and 10% other viable tissues. A facility weekly skin and wound evaluation dated 08/28/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.5 cm by 1.2 cm by 0.3 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. A facility weekly skin and wound evaluation dated 09/04/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.5 cm by 1.2 cm by 0.3 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound was stable. Review of a physician order dated 09/05/24 revealed an order for Resident #51 to be seen by wound consultant. A facility weekly skin and wound evaluation dated 09/11/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.4 cm by 1.0 cm by 0.2 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. A facility weekly skin and wound evaluation dated 09/18/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 2.6 cm by 1.8 cm. The wound was described as 80% slough and 20% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound was stable. A facility weekly skin and wound evaluation dated 09/24/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as stage IV pressure ulcer measuring 2.4 cm by 2.2 cm by 366462 Page 11 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 Level of Harm - Actual harm 0.4. The wound was described as 50% slough and 50% granulation tissue with a heavy amount of serous exudate. The edges were described as curled under. The facility determined the wound was stable, however the facility changed the treatment to cleanse with NS, apply Medi-honey then calcium alginate and cover with foam border dressing daily. Residents Affected - Few Review of physician's orders for September 2024 revealed an order dated 09/24/24 to cleanse left lateral foot wound with normal saline (NS), apply Medi-honey then calcium alginate and foam boarder dressing every night shift, cleanse wound to sacrum with NS, moisten gauze with NS then pack gently into wound and cover with foam dressing. A facility weekly skin and wound evaluation dated 10/01/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.6 cm by 1.6 cm by 0.2. The wound was described as 20% slough and 80% granulation tissue with a light amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. On 10/01/24 at 2:20 P.M., Licensed Practical Nurse (LPN) #209 and LPN #241 were observed to provide the physician ordered treatment to Resident #51's pressure ulcer. LPN #209 measured the wound at 1.6 cm by 1.6 cm by 0.2 cm. The wound bed was reddish with white rolled edges. LPN #241 applied Medi-honey to the wound bed, applied calcium alginate and covered with a foam border dressing. On 10/02/24 at 8:17 A.M., interview with Hospice Case Manager (HCM) #294 revealed the resident had multiple pressure ulcers, however the DTI on the left lateral foot was first identified as a DTI in February 2024 and Hospice Registered Nurse (HRN) #295 found the wound. During the interview, HCM #294 revealed it was difficult to communicate with the facility Unit Managers (UM) as well as the Director of Nursing (DON) due to facility having a lot of turnover (in staffing). On 10/02/24 at 9:14 A.M., interview with HRN #295 revealed she found the resident had a left lateral foot pressure ulcer/wound in February 2024. She said it was a deep tissue injury (DTI) and they were using a pad to protect the area due to the resident's contractures. She said then it just got worse. She said she gave the facility orders for the wound of pad and protect. She said the left lateral foot wound was almost healed and then opened again. She said when she was there on 09/30/24 during her routine visit his foot was soaked with drainage and she changed the dressing. She said the facility doesn't always date or initial the dressing, so she did not know how long this dressing was actually on the wound. She said the use of a moon boot as a preventative measure was not implemented until August 2024. She said the wound was just a red spot and then in August 2024 it deteriorated and opened. On 10/03/24 at 10:30 A.M. interview with the Director of Nursing (DON) verified the facility had no documented evidence that facility staff identified the development of the resident's pressure ulcer, assessed or monitored Resident #51's DTI/unstageable pressure ulcer with the onset of 02/06/24 until 08/13/24. Per record review, facility staff first documented the presence of the pressure ulcer on 08/09/24. On 10/03/24 at 2:10 P.M., interview with LPN #209 and #241 revealed a treatment to the DTI was initiated on 02/07/24 to pad and protect twice weekly until 02/12/24 when the treatment was changed to pad and protect daily. The treatment was discontinued on 02/14/24 and the wound did not have treatment until 02/16/24 when the pad and protect twice weekly on Monday and Friday was implemented. The treatment was discontinued on 04/12/24 when the facility implemented the same pad and protect treatment twice weekly on Monday and Friday. The facility then documented the ulcer was healed on 06/05/24 366462 Page 12 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0686 Level of Harm - Actual harm Residents Affected - Few (which was not accurate). LPN #209 and #241 verified they were unaware of hospice continuing the assessment and treatment of the wound following this date. LPN #209 revealed on 08/09/24 facility staff identified the resident had an unstageable pressure ulcer to the left lateral foot in the same area as the DTI. LPN #209 verified the facility had no comprehensive assessments of the DTI prior to the 08/13/24 assessment. Review of the facility policy titled, Skin and Wound Guidelines, last revised on 03/20/24 revealed skin alterations and pressure injuries were evaluated and documented by the licensed nurse. Weekly evaluations of the skin alteration in the resident's medical record by the wound team or licensed nurse per state and federal regulations. This deficiency represents non-compliance investigated under Complaint Number OH00158032 and Complaint Number OH00157831. 366462 Page 13 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure fall interventions were in place for one resident (#43) with a known fall history. This affected one (Resident #43) of three residents reviewed for falls. The facility census was 72. Findings Include: Review of the medical record for Resident #43 revealed an initial admission date of 05/06/19 with the diagnoses including aphasia, history of falls, chronic kidney disease, dysphagia, constipation, dry eye syndrome, pain, atrial fibrillation, hyperlipidemia, non-traumatic intracerebral hemorrhage, dementia, major depressive disorder, hypertension, aphasia, generalized muscle weakness, gastro-esophageal reflux disease, gastrointestinal hemorrhage, retention of urine and age related nuclear cataract. Review of the plan of care dated 08/23/22 revealed the resident was at risk for falls and had potential for injury related to deconditioning, incontinence, unaware of safety needs, vision/hearing problems, history of cerebrovascular accident, aphasia, cardiac medication use, history of falls, muscle weakness, pain, urinary incontinence, hard of hearing, depression, atrial fibrillation, as well as effects of other medications per order. Interventions included anticipate needs every shift, bed in lowest position when occupied, bed to be in low position when in bed, educate the resident/family/caregivers about safety reminders and what to do if fall occurs, encourage resident to be out of bed for meals, encourage resident to participate in activities that will promote exercise, physical activity for strengthening and improved mobility, fall evaluation per facility protocol, fall mat to floor on side of bed, labs per ordered, monitor for any changes in gait and/or ambulation, assist with ambulation as needed, monitor for any medication side effects and recent change in medication, abnormal labs, signs/symptoms of infection and pain as an increased risk for falls, report abnormal findings to primary care physician, neuro-checks as ordered, non-skid strips to floor in front of bathroom sink, non-skid footwear to be worn when out of bed, non-skid strips on floor to right side of bed and fall mat to be placed on top of these, notify family, physician and DON of any all type incident as soon as possible, therapy as ordered, resident needs activities that minimize the potential for falls while providing diversion and distraction and two handled cup for meals. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors, including rejection of care. The assessment indicated the resident had not had any falls since the prior assessment was completed. Review of the resident's fall risk evaluation dated 07/03/24 revealed the resident was at risk for falls. On 09/30/24 at 10:41 A.M., observation of Resident #43 revealed the resident's call light was laying on her night stand out of reach. On 09/30/24 at 10:45 A.M., interview with Licensed Practical Nurse (LPN) #198 verified the resident's call light was out of reach. 366462 Page 14 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00158032, Complaint Number OH00157831 and Complaint Number OH00157826. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366462 Page 15 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure Resident #31's oxygen nasal cannula was stored in a sanitary manner. This affected one resident (#31) of seven sampled residents. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the plan of care dated 09/16/24 revealed the resident had oxygen therapy related to COPD and respiratory failure with hypoxia. Interventions included encourage or assist with ambulation as indicated, give medications as physician ordered, monitor for signs/symptoms of respiratory distress and report to physician as needed, provide oxygen at six liters per nasal cannula and provide reassurance and allay anxiety. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident received oxygen. Review of the resident's physician's orders for September 2024 identified orders dated 08/28/24 change oxygen tubing, nasal cannula, oxygen masks, filters and humidification bottle every week and as needed, continuous oxygen at six liters per nasal cannula, may titrate oxygen to maintain oxygen saturation above 90% every shift, check placement and positioning of over the ear nasal cannula every shift and monitor skin on ears for signs/symptoms of breakdown. On 09/30/24 at 10:19 A.M., observation of the resident's emergency oxygen tank in the resident's room revealed the nasal cannula was wrapped around the oxygen holder and not in a protective bag. Further observation revealed a nebulizer machine sitting on the counter with the medication delivery system laying on the counter outside of a plastic bag. On 10/01/24 at 9:35 A.M., observation of the resident's emergency oxygen tank in the resident's room revealed the nasal cannula was wrapped around the oxygen holder and not in a protective bag. Further observation revealed a nebulizer machine sitting on the counter with the medication delivery system laying on the counter outside of a plastic bag. On 10/02/24 at 9:46 A.M., interview with Licensed Practical Nurse (LPN) #209 verified the oxygen nasal cannula and nebulizer delivery system was not stored appropriately. This deficiency was issued relative to incidental findings that were discovered during this complaint investigation completed on 10/10/24. 366462 Page 16 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure timely availability of medication for administration for one resident (#31). This affected one (Resident #31) of three resident received for new medication. The facility census was 72. Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the resident's physician's orders for September 2024 identified an order dated 09/21/24 Cepacol sore throat mouth/throat lozenge with the special instructions to give one by mouth ever two hours as needed for sore throat. Review of the resident's September 2024 Medication Administration Record (MAR) revealed the Cepacol sore throat lozenge ordered on 09/21/24 was given until 09/23/24 at 6:04 A.M. Review of the pharmacy delivery invoice dated 09/23/24 revealed the Cepacol sore throat lozenges were not delivered until 09/23/24. On 10/03/24 at 2:10 P.M., interview with Licensed Practical Nurse (LPN) #241 verified the Cepacol throat lozenge was not initiated in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00158259. 366462 Page 17 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to timely obtain a physician ordered laboratory test for one resident (#31). This affected one (Resident #31) of three reviewed for a change in condition. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the plan of care dated 09/05/24 revealed the resident had an alteration in elimination related to cognitive impairment, debility and generalized weakness. Interventions included assist with toileting and hygiene needs as needed, Braden scale upon admission, quarterly and as needed, incontinence care per facility policy, monitor urine for color, amount, consistency and order per physician's orders, record bowel movement and report any abnormalities, report changes in bowel movement frequently, consistency, and control to physician and scheduled toileting for bladder continence upon rising, before and after meals, at bedtime and three times during the night and as needed. Review of the resident's physician's orders for September 2024 identified an order dated 09/27/24 urinalysis and culture and sensitivity (UA/C&S). Review of the resident's progress note dated 09/30/24 at 5:38 P.M. revealed the resident's daughter was made aware the UA/C&S could not be obtained until 09/30/34 due to no laboratory services on the weekends. Review of the resident's progress note dated 10/01/24 at 5:10 P.M. revealed the urine for the UA/C&S was no longer needed as the resident was placed on an antibiotic for a urinary tract infection (UTI) on 09/30/24 during an emergency room (ER) visit. On 10/03/24 at 2:10 P.M., interview with Licensed Piratical Nurse (LPN) #209 verified the resident's urine for the physician ordered UA/C&S was not collected in a timely manner. This deficiency represents noncompliance investigated under Complaint Number OH00158032. 366462 Page 18 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0908 Keep all essential equipment working safely. 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, interviews and review of photographs, the facility failed to maintain resident equipment in good repair or a clean and sanitary manner. This affected one resident (#31) of three sampled residents. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #31 revealed an initial admission date of 08/27/14 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), anxiety disorder, major depressive disorder, herpes viral infection urogenital system, restless leg syndrome, vitamin D deficiency, neuropathy, hypothyroidism, peripheral vascular disease, acute and chronic respiratory failure with hypoxia, chronic peripheral venous insufficiency, spondylolisthesis of cervical region, osteoarthritis, scoliosis, generalized muscle weakness, edema, gastro-esophageal reflux disease, dependence on supplemental oxygen, hypertension, seasonal allergic rhinitis, pruritus, and nicotine dependence. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. On 09/30/24 at 10:00 A.M., interview with Resident #31 revealed her family member found her bed made with soiled linen that had dried brown and when the family member removed the soiled linen a rip in her mattress was found. The family member removed the protective covering and found the foam mattress was yellow with dried urine and feces. Resident #31 revealed the foam mattress had a strong odor of urine. On 10/01/24 at 1:10 P.M., interview with the resident's family member revealed she was assisting the resident back in bed and when she pulled the covers back the cloth incontinence pad was brown and had a strong odor of urine. She said she removed the soiled linen and was cleansing the mattress with disinfectant wipes when the odor of urine grew stronger and a rip in the mattress was observed. She revealed she unzipped the mattress protective cover and found the white foam mattress was stained yellow and brown. She revealed the yellow and brown stains were from urine and feces from former residents and her mother was sleeping on the mattress. Observations of photographs on the family member's phone at the time of the interview revealed a white foam mattress with a large yellow and brown stain. On 10/01/24 at 4:30 P.M., interview with the Administrator verified the mattress was not maintained in good repair or a clean and sanitary manner. This deficiency represents non-compliance investigated under Complaint Number OH00158259. 366462 Page 19 of 20 366462 10/10/2024 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation and interview, the facility failed to maintain a clean and sanitary environment. This affected one unit (500 unit) of four units. The facility census was 72. Findings Include: On 09/30/24 at 10:00 A.M., observation of Resident #31's carpeting revealed the carpet was stained with black and white spots. Interview with Resident #31 revealed the stains were present on the carpet when she was admitted and had offered to pay to have the carpeting shampooed. On 09/30/24 at 10:20 A.M., observation of room [ROOM NUMBER] (unoccupied) revealed the carpeting was stained black in multiple areas. On 09/30/24 at 10:21 A.M., observation of resident room [ROOM NUMBER] revealed the carpeting was stained black in multiple areas. On 10/03/24 at 10:30 A.M., interview with Licensed Practical Nurse (LPN) #155 verified the stained carpeting in rooms 506, 511,and Resident #31's room. This deficiency represents non-compliance investigated under Complaint Number OH00158259, Complaint Number OH00158032 and Complaint Number OH00157831. 366462 Page 20 of 20