Health inspection·February 15, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, medical record review, review of Self-Reported Incident (SRI), review of police report, and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#34) resident out of four residents reviewed for abuse. The facility census was 80. Findings included: 1. Review of the medical record for Resident #34 revealed an admission date of 07/19/16 with medical diagnoses of hypertension (HTN), nephrotic syndrome, heart disease, chronic obstructive pulmonary disease (COPD), and schizophrenia. Review of the medical record for Resident #34 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #34 was cognitively intact and was independent with eating, toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors. Review of the medical record for Resident #34 revealed a nurse progress note, dated 01/08/24 at 6:00 A.M. with stated Resident #34 reported to the nurse that his roommate, Resident #84, was physically aggressive towards him which was witnessed by staff. The note continued to state the two (#34 and #84) residents were separated, assessments were completed, and the physician was notified. The note stated no injuries were noted. 2. Review of the medical record for Resident #84 revealed an admission date of 11/11/23 with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of 02/13/24. Review of the medical record for Resident #84 revealed an admission MDS, dated [DATE], which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors. Review of the medical record for Resident #84 revealed a nurse progress note, dated 01/08/24 at 6:19 A.M., which stated Resident #84 initiated physical aggression towards his roommate Resident #34. The note stated Resident #84 informed the nurse that Resident #34 hit him on the left hip and lower back with the bathroom door before leaving their room. The note continued to state Resident #84 followed Resident #34 out into the hallway and started to hit Resident #34 with his walker in his back. The note stated the residents were separated and skin assessments were completed with no injuries noted. Page 1 of 4 365065 365065 02/15/2024 Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211

F 0600 Level of Harm - Minimal harm or potential for actual harm Interview on 2/15/24 at 10:01 A.M. with Resident #34 confirmed Resident #84 hit him with his walker in the hallway which was witnessed by staff. Resident #34 stated he had a little pain at the time of the incident but denied any injuries . Resident #34 stated the incident was unprovoked and denied hitting Resident #84 while in their room. Resident #34 stated Resident #84 was moved to a different room and there were no further incidents between the two residents. Residents Affected - Few Interview on 02/15/24 at 10:56 A.M. with Licensed Practical Nurse (LPN) #122 confirmed she witnessed Resident #84 intentionally hit Resident #34 with his walker while in the hallway on 01/08/24. LPN #122 stated she separated the residents and Resident #34 called the police to report the altercation. Interview on 02/15/24 at 12:00 P.M. with Director of Nursing (DON) stated an investigation was completed on 01/08/24 into the allegation of abuse by Resident #84 to Resident #34. DON stated she did not substantiate the allegation because she did not believe Resident #84 intentionally hit Resident #34 with his walker. DON stated Resident #84 was moved to a different room and there were no further incidents between the two residents. Review of the SRI report, dated 01/08/24, stated Resident #84 was observed by staff throwing his walker at Resident #34 and hitting him in the back. The report stated no injuries were noted and an investigation was completed. The facility did not substantiate the allegation of abuse. Review of the police report dated 01/08/24, Resident #84 was charged with simple assault. Review of the facility policy titled, Abuse and Neglect Protocols, stated residents have the right to be free abuse, neglect, misappropriation or resident property, exploitation, corporal punishment, physical or chemical restraints. The policy stated abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resident physical harm, pain, or mental anguish. This deficiency represents non-compliance investigated under Complaint Numbers OH00150614 and OH00150334. 365065 Page 2 of 4 365065 02/15/2024 Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 and pain specialist staff interviews, the facility failed to ensure a pain specialist appointment was scheduled and failed to effectively manage a resident's pain. This affected one (#84) resident out of three residents reviewed for pain management. The facility census was 80. Residents Affected - Few Findings included: Review of the medical record for Resident #84 revealed an admission date of 11/11/23 with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of 02/13/24. Review of the medical record for Resident #84 revealed an admission Minimum Data Set (MDS), dated [DATE], which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers. Review of the medical record for Resident #84 revealed a Nurse Practitioner (NP) note, dated 01/18/24, which revealed Resident #84 stated his current pain management was no longer working for his pain and Resident #84 asked for a pain management referral. The note stated Resident #84 rated his pain a seven out of ten on the pain scale. Review of the medical record for Resident #84 revealed a physician order, dated 11/14/23, for Norco 7.5-325 milligram (mg) one tablet by mouth every six hours as needed for pain and an order dated 11/11/23 for gabapentin 600 mg one tablet by mouth three times per day for pain. Further review of the physician orders revealed an order dated 01/29/24 for a consultation for pain management. Review of the medical record for Resident #84 revealed a nurse's note, dated 01/29/24 at 8:16 P.M. that stated a pain specialist office was contacted per the order and Resident #84's medical information was faxed to the office. The note stated the nurse was informed by the office staff that a determination would be made in three to four days if the pain specialist would accept Resident #84. Further review of the medical record revealed no documentation to support Resident #84 was scheduled an appointment with the pain specialist or that the facility followed up on the referral. Interview on 02/15/24 at 11:27 A.M. with Receptionist #210 from pain specialist office stated there was no documentation to support their office received a referral for Resident #84. Interview on 02/15/24 at 11:48 A.M. with Director of Nursing (DON) confirmed the facility staff did not follow up with the pain specialist office to schedule Resident #84's consultation appointment. DON also confirmed the medical record for Resident #84 did not contain any documentation to support the facility staff adjusted Resident #84's pain medications or offered other non-pharmacological interventions to effectively manage his pain. This deficiency represents non-compliance investigated under Complaint Number OH00150614. 365065 Page 3 of 4 365065 02/15/2024 Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211

F 0880 Provide and implement an infection prevention and control program. 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, observation, staff interview, and review of facility policies, the facility failed to follow infection control guidelines when administering medications. This affected one (#70) out of three residents reviewed for medication administration. The facility census was 80. Residents Affected - Few Findings included: Review of the medical record for Resident #70 revealed an admission date of 03/19/08 with medical diagnoses of depression, diabetes mellitus (DM), hypertension (HTN), chronic obstructive pulmonary disease, dementia, and schizoaffective disorder. Review of the medical record for Resident #70 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #70 had moderate cognitive impairment and was independent with eating, bed mobility and transfers. Review of the medical record for Resident #70 revealed a physician order dated 11/27/21 for metformin 500 milligram (mg) one tablet by mouth daily for DM, an order dated 01/13/22 for metoprolol 25 mg one tablet by mouth daily for HTN, and an order dated 06/30/22 for Risperdal one mg one tablet by mouth three times per day for schizoaffective disorder. Observation on 02/14/24 at 8:35 A.M. of Licensed Practical Nurse (LPN) #196 administering medications to Resident #70 revealed LPN #196 placed the metoprolol 25 mg tablet, the metformin 500 mg tablet, and the Risperdal one mg tablet directly into her bare hand from the pill card and then placed the medications into the pill cup. LPN #196 was observed handing the pill cup with the medications to Resident #70 who consumed the medication in the presence of LPN #196. LPN #196 did not wash her hands, use hand sanitizer, or use gloves before or after administering medications to Resident #70. Interview on 02/14/24 at 8:45 A.M. with LPN #196 confirmed she placed Resident #70's metoprolol, metformin, and Risperdal tablets directly into her bare hand then placed the medications into the pill cup prior to administering the medications to Resident #70. LPN #196 also confirmed she did not perform hand hygiene prior to or after administering medications to Resident #70. Review of the facility policy titled, Administering Medications stated the staff should follow infection control procedures (e.g. handwashing, antiseptic technique, gloves) for administering medications. Review of the facility policy titled Handwashing/Hand hygiene, revised August 2019, stated hand hygiene is the primary means to prevent the spread of infections. This deficiency is based on incidental findings discovered during the course of this complaint investigation. 365065 Page 4 of 4