Health inspection·June 6, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure one (Resident #2) of a in-facility census of 65 residents was treated with dignity and respect. Findings include: During an interview on 06/03/19 at 10:09 A.M., Resident #2 stated staff were very rude sometimes and did not listen to what she had to say. Review of Resident #2's medical record revealed diagnoses including adult failure to thrive and generalized anxiety disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was able to make herself understood and was usually able to understand others. Resident #2 was assessed as moderately cognitively impaired and required supervision for eating. On 06/03/19 at 12:18 P.M., Resident #2 arrived in the dining room. Resident #2 was served baked fish with lemon and a side of butter, watermelon, and a broccoli/cheese/rice casserole. Resident #2 attempted to get attention of staff several time by waving her hand before State Tested Nursing Assistant (STNA) #100 asked what was wrong. Resident #2 responded the fish was just stringy. STNA #100 offered Resident #2 a peanut butter and jelly sandwich. When STNA #100 asked dietary staff about an alternate, someone (not seen but heard) replied the fish was what Resident #2 requested. Resident #2 stated she did not like that kind of fish. Resident #2 complained, see when you don't like something you can't get anything else. STNA #100 asked Resident #2 if she wanted breaded fish and Resident #2 agreed stating maybe it would be better. At 12:27 P.M., Resident #2 was provided a piece of breaded fish and Resident #2 stated no and reported she did not like the cod, stating staff should know that. At 12:32 P.M., Resident #2 continued to complain about the fish crumbling but ate her watermelon. At 12:34 P.M., Dietary Staff #101 approached Resident #2 and asked Resident #2 what she wanted to eat. Resident #2 responded she did not like the cod but liked other kinds of fish. Resident #2 asked if salmon was available and Dietary staff #101 stated the salmon was frozen. Dietary staff #101 stated it would take a long time to defrost salmon and she would see what she could do. Resident #2 agreed to wait. On 06/03/19 at 12:41 P.M., Dietary Manager #102 approached Resident #2 and sat down beside her. Resident #2 voiced her concerns about the food she had been served. Dietary Manager #102 stated he had sent the cook down to talk to Resident #2 that morning and fixed the fish the way she wanted. Resident #2 stated she had told staff previously she did not like cod. Dietary Manager #102 stated cod was what was on the menu. Dietary Manager #102 informed Resident #2 he had taken sole fish out and and it would take 15-20 minutes to thaw in cold water. Resident #2 stated she just wanted a piece of Page 1 of 4 365114 365114 06/06/2019 Heritage Manor Jewish Hm For 517 Gypsy Lane Youngstown, OH 44504

F 0550 fried fish with no breading. Level of Harm - Minimal harm or potential for actual harm On 06/03/19 at 12:49 P.M., while Dietary Manager #102 and Resident #2 sat talking, Clinical Social Worker #103 approached, leaning over the table, and asked, in what sounded like accusatory manner, if Resident #2 was having a scene. Clinical Social Worker #103 stated staff spent a long time in Resident #2's room earlier that day talking about the fish. Clinical Social Worker #103 stated to Resident #2 if staff was fixing cod for everybody else they could not fix salmon just for her. Resident #2 stated when she filled out her menu she crossed out cod and wrote in salmon. At 12:55 P.M., Dietary Manager #102 stated he would provide Resident #2's fish when it was done. At 12:57 P.M., Dietary Staff #101 arrived with a piece of fish and Resident #2 stated it looked better. Resident #2 stated she appreciated it although she did make the statement the fish was soft but not crisp. Dietary Manager #102 stated he was going to leave and stated Resident #2 was not always going to get everything she wanted all the time. Resident #2 asked if fish was the only thing she got and if it was considered a meal. Dietary Staff #101 asked if Resident #2 wanted the broccoli and cheese casserole like she had been served earlier but had not eaten and asked if Resident #2 wanted noodles. Clinical Social Worker #103 stated those were her two options. Resident #2 agreed to try noodles. Dietary Manager #102 excused himself. As Dietary Staff #101 walked away, she stated here I go again. Resident #2 complained she did not believe the fish was cooked thoroughly and Clinical Social Worker #103 disagreed, stating there were too many people to cook for to cook everything exactly as everyone wanted. Resident #2 responded, stating maybe she was in the wrong place as there were too many people to provide food according to her preference. At 1:07 P.M., Dietary Staff #101 delivered the noodles. At 1:08 P.M., Resident #2 stated to Dietary Staff #101 that now she would remember she did not like cod fish and Dietary Staff #101 stated she already knew that. Resident #2 stated she liked the noodles. At 1:10 P.M., STNA #100 had approached and sat at the table with Resident #2 and Clinical Social Worker #103. Clinical Social Worker #103 stated it was impossible to please everyone. Residents Affected - Few On 06/03/19 at 1:11 P.M., Clinical Social Worker #103 was interviewed and stated Resident #2 was never going to be pleased. Clinical Social Worker #103 stated she worked for Jewish Family Services and has visited with Resident #2 since her admission focusing on the appropriate way to interact with others. Clinical Social Worker #103 stated she was walking down the hall when someone told her Dietary Manager #102 was in the dining room because Resident #2 was having a hissy fit. Clinical Social Worker #2 verified after she had approached Resident #2 and asked about her creating a scene (without taking the time to observe what was happening) she discovered Resident #2 was actually calm. Clinical Social Worker #103 stated maybe it was an assumption on her part when she heard Dietary Manager #102 was speaking with Resident #2 as he was not usually in the dining room. Clinical Social Worker #103 was informed eye rolling had been noted between staff during the conversations with Resident #2 and the statement from Dietary Staff #101 regarding Here I go again when she left to prepare noodles. Clinical Social Worker #103 agreed interactions could have been more respectful. Clinical Social Worker #103 stated she had spoken to Resident #2 about showing more appreciation or if she was more pleasant when asking for things staff would be happy to do things for her. Clinical Social Worker #103 agreed regardless of Resident #103's behavior, staff were expected to show respect and consideration. Clinical Social Worker #103 repeated stated Resident #2 could not be pleased. 365114 Page 2 of 4 365114 06/06/2019 Heritage Manor Jewish Hm For 517 Gypsy Lane Youngstown, OH 44504

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 record review and interview the facility failed to limit the use of as needed psychotropic medications as required for Resident #59 and Resident #26 and failed to attempt non-pharmacological interventions prior to the administration of anti-anxiety medication for Resident #26. This affected one of five residents reviewed for unnecessary medications and one of three residents reviewed for Hospice care. The in-house facility census was 65. Findings include: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease and Alzheimer's disease. She received Hospice services. The resident had an order dated 05/04/19 for Haloperidol lactate concentrate (an antipsychotic medication) 2 milligrams (mg) orally every six hours as needed for agitation for an indefinite time period. There was no evidence the physician examined the resident and determined the need to continue the as needed antipsychotic medication after 14 days. On 06/06/19 at 11:43 A.M. interview with the Director of Nursing (DON) verified the order for the antipsychotic medication exceeded the 14 day limit. 2. Review of Resident #26's medical record revealed diagnoses including Alzheimer's disease and organic mental syndromes with associated psychotic and/or agitated features. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated Resident #26 had delusions. On 05/10/19, a physician's order was written for Ativan (anti-anxiety medication) 1 milligram (mg) to be administered by mouth every four hours as needed for agitation with personal care. There was no limitation in the number of days the Ativan could be used. Review of May 2019 and June 2019 Medication Administration Records (MAR) revealed the Ativan ordered on an as necessary basis was administered 13 times with the most recent dose being administered 06/03/19. Documentation regarding the administration of Ativan did not consistently revealed staff attempted non-pharmacological interventions prior to its administration. On 06/06/19 at 11:43 A.M., the DON verified Resident #26 had an order to administer Ativan on an as necessary basis without a limit to the number of days the order could be used. On 06/06/19 at 12:15 P.M., the DON was informed a spot check of documentation regarding the administration of Ativan ordered on an as necessary basis during May and June 2019 was performed and revealed a lack of documentation regarding interventions attempted prior to the Ativan use. The DON stated the computerized charting system should prompt the staff to enter interventions and would see if could find additional information. On 06/06/19 at 1:20 P.M., Registered Nurse (RN) #104 provided three Behavior Monitoring assessments stating they were in a system not accessible to surveyors. RN #104 verified the three assessments did not correspond with dates/times the Ativan was administered. RN #104 stated nurses filled the behavior monitoring out each shift and verified some of the interventions listed such as offering 365114 Page 3 of 4 365114 06/06/2019 Heritage Manor Jewish Hm For 517 Gypsy Lane Youngstown, OH 44504

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few toileting and food/fluids would be interventions provided to every resident every shift and not specifically geared toward behaviors. Review of the facility's Anti-Psychotic Drug Use policy, effective April 2018, revealed as needed orders for psychotropic drugs were limited to 14 days, except as provided if the attending physician or prescribing practitioner believed that it was appropriate for the as needed order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for the as needed order. As needed orders for antipsychotic drugs were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication 365114 Page 4 of 4