Health inspection·April 5, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, medical record review, policy review and staff interviews, the facility failed to ensure a urinary catheter drainage bag was appropriately covered. This affected one of one (#45) of one residents reviewed for dignity. The facility identified nine residents with urinary catheters. The facility census was 118. Findings include Review of Resident #45's medical record revealed an admission date of 09/11/18 and diagnoses included: sepsis, a pressure ulcer of the sacral region, osteomyelitis, chronic kidney disease stage three, anemia, respiratory failure, hypotension and quadriplegia. Observation on 04/02/19 at 11:06 A.M. and on 04/03/19 at 11:34 A.M., revealed Resident #45's urinary catheter drainage bag was not covered. Interview on 04/03/19 at 11:36 A.M., with Licensed Practical Nurse (LPN) #256 verified Resident #45's urinary catheter drainage bag was uncovered. LPN #256 told Resident #45 she would get a cover. Interview on 04/03/19 at 1:42 P.M., with the Assistant Director of Nursing (ADON) #243 revealed urinary catheter drainage bags should be covered. Review of the policy, Catheter-Foley Insertion, Maintenance and Removal last revised 06/04/14, revealed no guidelines for covering a urinary drainage bag when the resident was in their room. Page 1 of 17 365093 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident and staff interviews, the facility failed to ensure residents and resident representatives were given an opportunity to participate in the care planning process. This affected two (#12 and #88) of 26 residents reviewed for care plans. The facility census was 118. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 03/30/18, with diagnoses including: Diabetes Mellitus, acute kidney failure, and cerebralvascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Review of the resident's Interdisciplinary Team Care Conference Summary forms dated 04/10/18, 07/10/18, 10/02/18, and 01/01/19 revealed a documented Care Conference was held for the resident. Multiple staff members signed the form indicating they were in attendance. None of the forms contained the resident or the resident's wife's signatures. Review of the resident's progress notes revealed documentation dated 10/02/18 at 1:30 P.M., of a care conference held this date with the resident and his wife. No other documentation of a care conference for Resident #12 could be found in the progress notes. Interview on 04/02/19 at 10:53 A.M., with Resident #12 revealed he had no recollection of being invited to or attending any care conferences since his admission to the facility. Interview on 04/03/19 at 2:00 P.M., with Licensed Practical Nurse (LPN) #215 verified the resident and his wife attended a care conference on 10/02/18, but could not provide evidence the resident and his wife were invited to or attended care conferences on 04/10/18, 07/10/18, or 01/01/19. Interview on 04/04/19 at 11:27 A.M., with State Tested Nursing Assistant (STNA) #260 verified she signed the resident's Interdisciplinary Team Care Conference Summary forms dated 04/10/18, 07/10/18, and 01/01/19. STNA #260 stated she was unable to verify if the resident and/or his wife attended a care conference on these dates because she did not actually attend the meetings. STNA #260 revealed LPN #215 periodically prided her with a stack of Interdisciplinary Team Care Conference Summary forms for multiple residents, and have her sign them indicating she attend the meetings. 2. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, difficulty swallowing, throat cancer, and dementia. Resident #88's admission MDS assessment dated [DATE], identified no behaviors or mood issues. The assessment identified Resident #88 had a BIMS (brief interview for mental status) score of 11, which identifies mildly impaired cognition. Review of the resident's Interdisciplinary Team Care Conference Summary forms dated 02/06/19, 02/13/19 and 02/27/19 revealed a documented care conference was held for the resident. Staff member RN #216 and STNA #260 signed the form indicating they were in attendance. None of the forms contained the resident or the resident's families signature. Interview with the facility DON on 04/04/19 at 2:46 P.M., verified she could not locate any 365093 Page 2 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0553 Level of Harm - Minimal harm or potential for actual harm information that identified Resident #88 and or his family was invited and or attended any care plan meetings regarding his care. Review of a facility policy titled, Care Plan Meeting, dated 02/02/15, revealed the policy did not address inviting the resident or the resident's representative to care conferences. Residents Affected - Few 365093 Page 3 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

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 policy review, the facility failed to notify a resident's physician and family of a significant weight loss. This affected one (#6) of two residents reviewed for nutrition. The facility census was 118. Finding include Record review of Resident #6's medical record revealed an admission date of 08/16/16, with diagnoses including: Alzheimer's disease, dysphagia, difficulty walking, dementia, anxiety and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the monthly weight report revealed Resident #6 weighed 94 pounds on 02/01/19. Resident #6 weighed 89 pounds on 03/01/19 indicating a 5.32% weight loss in thirty days. Review of a health status progress note dated 03/01/19 at 4:12 P.M., revealed Resident #6 had a significant weight loss of 5.3 percent in the past 30 days. Review of the nurse's progress notes from 03/01/19 through 04/02/19 revealed no documentation Resident #6's physician or family were notified of the significant weight loss noted on 03/01/19. Interview on 04/04/19 at 12:50 P.M., with the Director of Nursing (DON) revealed Resident #6's family was notified of the significant weight loss on 04/03/19 and the physician was notified on 04/04/19. Review of the policy Physician Notification, last revised 07/16/12, revealed physicians would be notified by fax for non-urgent updates. Review of the policy Resident and Family notification last revised 07/10/11, revealed the facility would immediately, within a reasonable time frame, inform the resident and/or power of attorney of any changes in the resident's condition. 365093 Page 4 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

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 and staff interview, the facility failed to provide written notification to residents and resident representatives of emergency transfers to the hospital. This affected three (#98, #101 and #314) of five residents reviewed for discharge. The facility census was 118. Findings include: 1. Review of Resident #314's medical record revealed an admission date of 07/28/16, with a most recent readmission date of 03/26/19. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired. Review of the facility's Resident Transfer Forms for Resident #314 revealed the resident was transferred to an acute care hospital on [DATE], 12/28/18, and 03/21/19. No documentation was available of the facility providing written notification to the resident, the resident's representative, or the State Ombudsman's office of the emergency transfers. 2. Review of Resident #98's medical record revealed an admission date of 09/26/18. The medical record identified Resident #98 required hospitalization on 01/05/19 and 01/30/19. The record further identified Resident #98 was alert, oriented and able to make his needs known. The medical record contained no documentation of any notification to the resident and or family regarding the reason for the emergency discharge to the hospital. 3. Review of Resident #101's medical record revealed an admission date of 01/25/19. The record confirmed Resident #101 was alert, oriented and able to make all her needs known. The record further identified Resident #101 required hospitalization on 01/28/19. The medical record contained no documentation of any notification to the resident and or family of the hospitalization. Interview on 04/03/19 at 1:44 P.M., with the Administrator verified the facility did to provide written notification to the resident or the resident's representative of the three resident's emergency transfers. The Administrator further revealed the current policy, at the time of the survey, did not address providing written notification to residents or residents representatives of emergency transfers. 365093 Page 5 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

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, bed hold notification policy and staff interview, the facility failed to provide a medicaid resident with bed hold notice upon transfer to the hospital. This affected one (#101) of five residents reviewed for hospitalization. The facility census was 118. Findings include: Review of Resident #101's medical record revealed an admission date of 01/25/18. The record revealed Resident #101's payer source was medicaid. The record further identified Resident #101 required hospitalization on 01/28/19. The record was silent to any notification of bed hold upon discharge to identify the number of bed hold days Resident #101 had left. Resident #101 was readmitted to the facility on [DATE]. Review of the facility's current admission packet identified bed reserve policy dated 05/26/18, identified the facility follows the state Medicaid plan which reimburses up to 30 days for hospitalization per calendar year. The policy did not contain any need to notify residents upon hospitalization of the days left. Interview with the facility Director of Nursing on 04/04/19 at 10:19 A.M., confirmed the facility does not provide residents with bed hold notification to any residents upon discharge. The DON confirmed the facility goes over the bed hold policy upon admission but were unaware they needed to do this upon transfer to the hospital. 365093 Page 6 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0641 Ensure each resident receives an accurate assessment. 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, Minimum Data Set (MDS) Resident Assessment Instrument manual review and staff interviews, the facility failed to ensure MDS assessments were accurate. This affected four (#6, #86, #56, #98) of 26 resident MDS assessments reviewed. The facility census was 118. Residents Affected - Some Findings include: 1. Review of Resident #6's medical record review revealed an admission date of 08/16/16, with diagnoses including: Alzheimer's disease, dementia, dysphagia, difficulty walking, dementia, anxiety and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment and a weight gain. Review of the monthly weight report revealed Resident #6 weighed 94 pounds on 02/01/19. Resident #6 weighed 89 pounds on 03/01/19 indicating a 5.32% weight loss in thirty days. Review of a health status progress note dated 03/01/19 at 4:12 P.M., revealed Resident #6 had a significant weight loss of 5.3 percent in the past 30 days. Interview on 04/05/19 at 9:39 A.M., with the MDS Director #216, confirmed a coding error occurred and the quarterly assessment should have reflected the significant weight loss. 2. Review of Resident #86's medical record revealed and admission date of 05/15/17, with diagnoses including: depressive disorder, dysphagia, excoriation disorder, hypertension, muscle weakness, cerebral infarction, type two diabetes mellitus, and repeated falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #86 was cognitively impaired and had no falls since her annual assessment dated [DATE]. Review of a nurse's note date 01/23/19 revealed Resident #86 was on the floor face down with scratch and hematoma noted by the right eye. Resident #89 was sent to the emergency room. Interview on 04/03/19 at 11:10 A.M., with MDS Director #216, revealed the fall on 01/23/19 was not documented on the quarterly MDS assessment dated [DATE]. 3. Review of Resident #56's medical record review revealed admission date of 02/17/14, with diagnoses including: hypertension, Alzheimer's disease, and sciatica of the right side. Review of the quarterly MDS assessment, dated 01/29/19, under section N-410H, did not identify Resident #56 received opioid pain medication. Review of the resident's physician orders revealed on 01/23/19 the resident was ordered Tramadol (opioid pain medication) 50 milligrams (mg) to be administered every eight hours as needed for pain. Review of Resident #56's Medication Administration Record (MAR) revealed the resident was administered Tramadol 50 mg on 01/24/19, 01/28/19, and 01/29/19. 365093 Page 7 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 04/04/19 at 9:54 A.M., with Licensed Practical Nurse (LPN) #215 revealed she was the MDS coordinator and completed Resident #56's quarterly MDS assessment dated [DATE]. LPN #215 confirmed Resident #56's section N-410H should have identified she was receiving opioid medication. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, chapter three, page N-10, dated 10/2017, revealed opioid medication received by a resident should be coded on the MDS assessment at N-410H. 4. Review of Resident #98's medical record revealed an admission date of 09/26/18, with diagnosis including: stage 4 pressure ulcers to the coccyx, fractured 5th vertebra and paraplegia. Resident #98 had re-admissions from the hospital on [DATE]. Review of the quarterly MDS assessment dated [DATE] and 02/28/19 revealed the assessments both identified Resident #98 had one unstageable pressure ulcer. Review of the facility wound physician notes dated 12/05/18 identified development of two additional pressure ulcers. The ulcers were identified on the left and right gluteal folds. Interview with Registered Nurse (RN) #216, on 04/05/19 at 9:13 A.M., revealed Resident #98 had four total pressure areas since 12/05/19 and they were not properly identified on Resident #98's MDS. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, chapter three, page M-6, dated 10/2017, revealed pressure ulcers should be coded on the MDS assessment. 365093 Page 8 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview, the facility failed to complete a recapitulation/discharge summary for a resident discharged from the facility. This affected one (#113) of one reviewed for discharge. The facility census was 118. Findings include: Review of Resident #113's closed medical record revealed an admission date of 01/04/19 and discharged to home on [DATE]. Diagnoses included: congestive heart failure, admitted with right femur and right radius fractures and patella fracture, Parkinson's disease and macular degeneration. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #113 was cognitively intact with no noted behaviors. Review of Section Q - Participation in Assessment and Goal Setting revealed the resident participated in the assessment and goal setting and expected to be discharged to the community. Review of the progress notes dated 01/09/19 revealed the resident was discharged home with Palliative care. Further review of the complete medical record revealed there was no evidence of a discharge summary or recapitulation of care. Interview on 04/04/19 at 4:10 P.M., with the Director of Nursing verified there was no discharge summary or evidence of recapitulation of the resident's stay. 365093 Page 9 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to initiate restorative programs for one (#88) of 26 sampled residents. The facility census was 118. Residents Affected - Few Findings include: Review of Resident #88's medical record revealed an admission date of 01/28/19, following a hospitalization. The record identified prior to admission Resident #88 resided at home with his daughter. Review of the discharge plan of care, dated 03/20/19 identified Resident #88 plans on returning home following rehabilitation at the facility. Review of the Therapy Restorative Recommendation dated 03/23/19, revealed orders for a restorative walking and dressing/grooming programs. Further review of the medical record revealed as of 04/04/19, there was no documentation of the restorative programs being initiated. Interview with Registered Nurse (RN) #130, on 04/04/19 at 1:44 P.M., revealed she was in charge of the restorative programs at the facility. The interview identified when residents are discharged from therapy, they recommend restorative programs. RN #130 identified therapy completes a Therapy Restorative Recommendation form and places it into her mailbox. RN #130 confirmed Resident #88 restorative form was located in the resident's paper chart and she had no seen and or started him on any of the recommended restorative programs. 365093 Page 10 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, staff and resident interviews, the facility failed to provide restorative range of motion services. This affected two (#9 and #88) of two residents reviewed for restorative. The facility census was 118. Findings include 1. Review Resident #9's medical record revealed an admission date on 10/08/14. Diagnoses included atherosclerosis of native arteries of the right leg with ulceration of the heel and midfoot, peripheral vascular disease, hypertension and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. Review of a physician order dated 01/10/19 revealed Resident #9 was ordered seated active range of motion (AROM) to the bilateral upper extremities for 15 minutes a day, six to seven days per week. Review of restorative task documentation from 03/05/19 through 04/03/19, revealed Resident #9 was not offered AROM on 18 days. Resident #9 received AROM on 03/25/19, 03/26/19, 03/28/19, 04/01/19 and 04/03/19. Resident #9 refused AROM on seven days. Interview on 04/02/19 at 10:45 A.M., with Resident #9, revealed the restorative aide use to complete exercises with him but then she left. Interview on 04/04/19 at 10:29 A.M., with the Restorative Aide (RA) #100, verified the last restorative aide had left the position. RA #100 revealed a new restorative aide was being trained. RA #100 revealed Resident #9 had not received restorative services as ordered as there was not a staff member trained to provide the restorative exercises. Review of the policy Restorative Nursing, last revised 07/08/12 revealed restorative programs would be initiated as needed upon referral from other health care team members. Individualized nursing intervention would be implemented to assist or promote each resident's ability to attain his/her maximum functional potential. 2. Review of Resident #88's medical record revealed an admission date of 01/28/19, following a hospitalization. The record identified prior to admission Resident #88 resided at home with his daughter. Review of the discharge plan of care, dated 03/20/19 identified Resident #88 plans on returning home following rehabilitation at the facility. Review of the Therapy Restorative Recommendation dated 03/23/19, revealed orders for a range of motion programs. Further review of the medical record revealed as of 04/04/19, there was no documentation of the restorative programs being initiated. Interview with Registered Nurse (RN) #130, on 04/04/19 at 1:44 P.M., revealed she was in charge of the restorative programs at the facility. The interview identified when residents are discharged from therapy, they recommend restorative programs. RN #130 identified therapy completes a Therapy 365093 Page 11 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0688 Level of Harm - Minimal harm or potential for actual harm Restorative Recommendation form and places it into her mailbox. RN #130 confirmed Resident #88 restorative form was located in the resident's paper chart and she had no seen and or started him on any of the recommended restorative programs. Residents Affected - Few 365093 Page 12 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, facility policy review, resident and staff interviews, the facility failed to implement interventions to prevent falls. This affected one (#88) of three sampled residents reviewed for accidents. The facility also failed to ensure staff did not leave medications, unattended in one resident's room (Resident #98). This could potentially affect three (#57, #67, and #77) residents identified by the facility as confused and independently mobile. The facility census was 118. Findings include 1. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, diarrhea, difficulty swallowing, throat cancer, and dementia. Review of the admission assessment (MDS) dated [DATE] identified Resident #88 was high risk for falling and a written plan of care was required. The assessment further identified Resident #88 required extensive assistance of two persons for transfers. Resident #88's medical record identified while in the facility falls occurred on 02/03/19, 02/07/19, 02/10/19, 03/06/19, 03/10/19, 03/12/19, 03/16/19 and 04/01/19. The facility was noted to conduct investigations with all falls and identified interventions needed to attempt to prevent Resident #88 from falling. The fall occurring 04/01/19 identified the nature of the fall included Resident #88 self transferred from his wheelchair and fell. The listed intervention at that time was re-direct resident from sitting in his room alone. Observation of Resident #88 occurred on 04/04/19 at 4:18 P.M., revealed Resident #88 was in his wheelchair sitting alone in his room. Interview with State Tested Nursing Assistant (STNA) #58 was conducted on 04/04/19 at 4:24 P.M., identified staff use a card ([NAME]) located in the closet door to identify current interventions for falling for each resident. The interview confirmed Resident #88 does not have the card located in the door and she was unable to identify any location of Resident #88's fall interventions. The interview further confirmed the STNA's get report for other staff during shift change, but she was unaware Resident #58 was not to be left alone, while in his wheelchair in his room. Observation of Resident #88 occurred on 04/05/19 at 7:51 A.M., to be up in his wheelchair, alone in his room. Resident #88 was getting clothing out of the closet at that time. Interview with STNA #115 occurred on 04/05/19 at 7:53 A.M. The interview identified she was not aware of where to find fall interventions that should be in place for Resident #88. STNA #115 confirmed she was not aware Resident #88 should not be left alone in his room or his high number of fall. Interview with Registered Nurse (RN) #216 occurred on 04/04/19 at 4:45 P.M., confirmed a [NAME] is completed for all residents upon admission and is placed in their closet in the room. The interview identified STNA's utilize these to know what care they need to provide to residents. The interview confirmed RN #216 could not locate a [NAME] for Resident #88. The interview confirmed the current written plan of care does not include all interventions developed following falls occurring. The plan does not include: early sense (device located on bed to notify staff of movement), not to leave resident alone in room in wheelchair, and ensure laying resident down after radiation treatments. 365093 Page 13 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident #98's medical record review revealed an admission date of 03/21/19. Diagnoses included: Diabetes mellitus, hyperlipidemia, and anxiety. Review of the admission assessment dated [DATE] revealed the resident was alert and oriented to person, place, and time. Observation of Resident #98's room on 04/02/19 at 8:43 A.M., revealed a medicine cup sitting on a bedside table near the resident. There were 12 pills noted in the medicine cup. Interview at this time with Resident #98 revealed the nurse brought him the medication and left them for him to take. Interview on 04/02/19 at 8:50 A.M., with Licensed Practical Nurse (LPN) #256 revealed she gave Resident #98 his pills this morning. LPN #256 verified she left the resident's pills on his bedside table while she went to provide care for another resident. LPN #256 revealed she should have waited for the resident to take the medication before leaving the room. Interview on 04/03/19 at 1:00 P.M., with the Director of Nursing (DON) revealed it was against the facility's standard of practice to leave medications in resident's rooms unattended. Nursing staff were to remain with the resident until the medications were consumed to verify the resident took them. The DON identified three residents (#57, #67 and #77) as being confused and independently mobile. Review of a facility policy titled, Medication Administration Specific Procedures, dated 03/01/07, revealed it was the facility's policy to administer medications in an organized and safe manner. 365093 Page 14 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, medical record, facility policy and staff interview, the facility failed to administer physician ordered tube feeding in accordance with the orders. This affected one (#2) random resident observed of 13 residents identified receiving enteral tube feeding. The facility census was 118. Findings include: Review of Resident #2's medical record revealed re-admission date of 01/06/19, with medical diagnosis including: dysphasia, respiratory failure and tracheotomy. Review of the physician orders for April 2019 identified Resident #2 should be receiving enteral tube feeding (Isosource 1.5) 40 milliliter/hour (ml/hour) via peg tube around the clock. Observation of Resident #2 on 04/04/19 at 8:30 A.M., during her medication administration time, revealed Resident #2 was noted to be receiving enteral tube feeding at that time of Isosurce 1.5 at a rate of 60 ml/hour. The observation identified the bag of solution hanging did not include the rate at which the feeding should be infused. Registered Nurse (RN) #233 was observed to place the tube feeding on hold, administer Resident #2's medication and restart the enteral feeding at 60 ml/hour. Interview with RN #233 on 04/04/19 at 8:42 A.M., confirmed the current medication administration record (MAR) identified Resident #2 should be receiving her enteral feeding at 40 ml/hour. RN #233 then entered Resident #2's room and changed the feeding rate to 40/ml hour and confirmed there was no rate identified on the bag currently hanging. RN #233 obtained Resident #2's current physician orders and confirmed Resident #2 should be receiving the tube feeding at 40 ml/hour and she is not sure when or whom had started Resident #2's tube feeding pump at 60 ml/hr. Review of the facility policy titled Enteral Feeding dated 01/30/07, identified feeding container is to be labeled with formula name, strength, rate, date, time, patient name and nurses initials. 365093 Page 15 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, the facility failed to ensure a resident receiving an anti-psychotic medication had a justified medical diagnosis to support the use. This affected one (#88) of five residents reviewed for medications. The facility census was 118. Findings include 1. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, diarrhea, difficulty swallowing, throat cancer, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], identified Resident #88 was receiving an anti-psychotic medication (Seroquel 200 mg) and identified no behaviors or mood issues. The assessment identified Resident #88 had a BIMS (brief interview for mental status) score of 11, which identifies mildly impaired cognition. Further review of the record identified no targeted behaviors Resident #88 was being evaluated for. The medical record identified no psychiatric history and or targeted behaviors Resident #88 may have. Review of a facility Interdisciplinary Team Care Conference Summary dated 02/27/19 identified Resident #88 was receiving Seroquel. The form had a section for Psychotropic medication usage. The form also identified reasons for the medications continue to be valid. The form dated 02/27/19 was blank in the area that identified the validation for use of the medication for Resident #88. The form also lacked any resident and or family involvement in that meeting. Interview with Registered Nurse (RN) #288 occurred on 04/04/19 at 1:13 P.M., revealed she was not sure why Resident #88 was on Seroquel, but that he was admitted with the medication. RN #288 suggested to call Resident #88's son, whom is a Pharmacist. The interview confirmed the facility does not have any targeted behaviors listed for Resident #88. A telephone interview was completed with Resident #88's daughter, whom is also listed as Power of Attorney (POA), on 04/04/19 at 1:37 P.M. Resident #88's POA identified she believed the medication Seroquel was used for an anti-depressant. The daughter confirmed she provided care for Resident #88, at her home prior to admission and there is no history of mental illness and or behaviors. Telephone interview was conducted with Resident #88's son on 04/04/19 at 2:09 P.M. The interview identified he had no idea why his father was taking a anti-psychotic medication and confirmed he has no history of mental illness or behaviors. 365093 Page 16 of 17 365093 04/05/2019 Good Shepherd The 622 Center St Ashland, OH 44805

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. Based on observation and staff interview the facility failed to ensure necessary room repairs were completed. This affected three of 32 resident rooms observed. Residents #84, #87, #29, #6, #172, and #49 resided in these rooms. The facility census was 118. Findings include 1. Observation on 04/03/19 at 2:55 P.M. in the shared bathroom of Resident #84 and Resident #87 revealed there was no mopboard. The drywall was exposed and damaged at the base of the bathroom walls. Interview on 04/03/19 at 2:55 P.M., with the Director of Environmental Services (DES) #300 revealed the damage was caused by a water leak in another room in January. DES #300 revealed it was an oversight the bathroom mopboard had not been replaced. 2. Observations on 04/03/19 at 2:55 P.M. and 3:02 P.M., revealed water stained ceiling tiles in two bathrooms shared by four residents (#6, #29, #172, #49). Interviews on 04/03/19 at 2:55 P.M. and 3:02 P.M. with the Director of Environmental Services (DES) #300 confirmed the ceiling tiles in the two bathrooms were stained. DES #300 stated staff should report rooms in need of repair. The facility was unable to provide a policy related to resident room maintenance. 365093 Page 17 of 17