Health inspection·October 18, 2018

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #39's medical record revealed an admission date of 06/01/16. Diagnoses included Schizophrenia and brief psychotic disorder. Review of the resident's annual Minimum Data Set (MDS) assessment, dated 09/28/18, revealed the resident was cognitively intact and required supervision for activities of daily living. No negative behaviors were documented. Residents Affected - Few Review of Resident #39's care plan revealed the resident tended to hoard items in his/her room. The resident was encouraged to clean up and remove the extra items in his/her room and the resident's room would be checked for items that need to be removed at least weekly. Review of a social service note, dated 09/24/18, revealed the Licensed Social Worker (LSW) #500 spoke to Resident #39 regarding the cleaning of his/her room the previous week. SR #1 reported he/she was remorseful about items being thrown away. Interview with Resident #39 on 10/15/18 at 2:58 P.M. revealed last month the facility Administrator and LSW #500 came into his/her room and began throwing his/her personal items away. Items thrown away included multiple pairs of blue jeans, a box of important papers and two cellular telephones. Resident #39 revealed the Administrator searched every drawer, box and closet and would inform the resident that he/she did not need the items and threw his belongings in the garbage. Resident #40 informed his/her guardian of the situation. Telephone interview with Resident #39's legal guardian on 10/16/18 at 1:50 P.M. revealed she/he agreed that the resident's room needed cleaning and she/he was discussing the situation with the facility social worker. The guardian stated he/she had informed the LSW that the guardian wanted to be present while the room was being cleaned. The guardian stated he/she was not alerted of the day of the cleaning so was not in the facility to provide emotional support to Resident #39 during the task. Resident #39 suffered from Schizophrenia and needed support during the cleaning process. In addition, the guardian revealed items thrown away included two cellular telephones, blue jeans and a box of important papers. Interview with LSW #500 on 10/17/18 at 9:42 A.M. revealed Resident #39 collected many items, especially food sent by his/her family. Resident #39 was alerted two to three days in advance that the room would be cleaned by staff. The LSW stated the items thrown away were expired Girl Scout cookies, socks and underwear. The LSW stated two cellular telephones were thrown away because the resident stated the phones did not work. The LSW verified the guardian was failed to be notified of the date of the room cleaning. Review of the facility's Resident's [NAME] of Rights undated, revealed nursing home residents have Page 1 of 8 365155 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

F 0552 the right to have any significant change reported to their sponsor. Level of Harm - Minimal harm or potential for actual harm This deficiency substantiates Complaint Number OH00100526. Residents Affected - Few Based on record review, family interview, resident interview, guardian interview and staff interview, the facility failed to notify a resident's family of results of laboratory testing and failed to notify Resident #39's guardian timely regarding room cleaning. This affected two (Resident #39 and #40) of two residents reviewed for notification. The facility census was 84. Findings include: 1. Medical record review revealed Resident #40 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, delusional disorder, and anxiety. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 08/27/18, revealed the resident's cognition was severely impaired. Review of laboratory test for Resident #40 revealed an urinalysis was performed for the resident on 07/16/18. There was no evidence the resident's son was notified of the urinalysis results from 07/16/18 through 10/16/18. Interview on 10/16/18 at 9:58 A.M. with Resident #40's son revealed he was the responsible party for his mother's care. The resident's son revealed, a couple months prior, he requested for the facility to collect an urinalysis from his mother due to symptoms he was seeing. The son revealed he was never informed of the results from the urinalysis. The son further revealed he inquired a couple times to the nurse on duty, but was told they would get back to him with the results. No one ever did. Interview on 10/17/18 at 2:25 P.M. with the Director of Nursing (DON) revealed staff were to notify the resident and/or resident's representative of all ordered test and new orders. The DON further revealed staff should notify the resident and/or resident's representative of laboratory test, regardless of the results. The DON verified there was no evidence Resident #40's son was notified of the results of the urinalysis performed on 07/16/18. 365155 Page 2 of 8 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on resident interviews, staff interview, record review and review of facility policy, the facility failed to provide showers for residents unable to carry out activities of daily living independently. This affected two (Resident #7 and #24) of three residents reviewed for showers. The facility identified 57 residents who require assistance with showers. The facility census was 84. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 08/09/18. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, acute and chronic respiratory failure and dependence on supplemental oxygen. Review of Resident #24's comprehensive Minimum Data Set (MDS) assessment, dated 08/09/18, revealed the resident had intact cognition. The resident extensive assistance of two staff for bed mobility, transfers, and dressing. Review of Resident #24's care plan revealed the resident was scheduled for showers every Wednesday and Saturday on the second shift. Review of Resident #24's shower documentation revealed the resident failed to receive showers on 08/15/18, 08/18/18, 08/29/18, 09/01/18, 09/15/18, 09/29/18, 10/03/18 and 10/06/18. Review of Resident #24's medical records revealed no documentation or reasoning of why the resident failed to receive showers. Interview with the Director of Nursing (DON) on 10/17/18 at 2:56 P.M. verified Resident #24 failed to receive an adequate number of required showers per schedule for Resident #24. 2. Review of the medical record for Resident #7 revealed an admission date of 10/19/16. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease, chronic respiratory failure, and depression. Review of Resident #7's MDS revealed the resident was cognitively intact and required extensive assistance with personal hygiene and bathing. Review of Resident #7's shower documentation revealed the resident was to receive showers on second shift every Monday and Thursday. Review of Resident #7's shower documentation revealed the resident failed to receive showers on 09/17/18, 09/24/18, 10/01/18 and 10/15/18. Interview with Resident #7 on 10/17/18 at 8:55 A.M. revealed the resident was informed by staff that there was no time to give the showers on the days missed showers would be given on the following shift. Resident #7 stated the showers were not accommodated on the following shifts. Interview with the Director of Nursing (DON) on 10/18/18 at 10:35 A.M. verified Resident #7 failed to receive an adequate number of required showers per schedule for Resident #24. Interviews with State Tested Nursing Aides (STNA) #410, #415 and #420 on 10/16/18 between 9:30 P.M. and 11:40 P.M. revealed periodically showers were unable to be completed on second shift due to 365155 Page 3 of 8 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

F 0677 call offs. Showers were to be completed on the following shift. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Bathing: Shower dated 10/21/01 revealed the purpose of bathing was to provide cleanliness and comfort, stimulate circulation and observe condition of resident. Residents Affected - Few This deficiency substantiates Complaint Number OH00100313. 365155 Page 4 of 8 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

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. Based on record review, observation, review of facility policy, and staff interview, the facility failed to ensure staff maintained resident's assistive devices to prevent accidents. This affected one resident (#30) of one residents reviewed for falls. The facility identified 27 residents with personal safety alarms. The facility census was 84. Findings Include: Review of Resident #30's medical record revealed an admission date of 11/10/17. Diagnoses included cerebral infarction, dementia, and hemiplegia of the right side. Review of Resident #30's quarterly Minimum Data Set (MDS) assessment, dated 08/14/18, revealed the resident had a moderate cognitive deficit and required extensive assistance in all activities of daily living except eating. Review of Resident #30's Fall Risk Evaluation, dated 10/14/18, revealed the resident was at a high risk for falls. Review of Resident #30's medical record dated 10/15/18 at 2:13 P.M. revealed the resident fell which resulted in a laceration on right forehead requiring 12 staples. In addition, Resident #30 suffered bruising to bilateral facial bones, nose and forehead. Review of physician's order, dated 11/11/17, revealed an order for a personal safety alarm (PSA) to the wheelchair. Review of Resident #30's most recent care plan revealed the resident required a PSA to the bed and while in the wheelchair. Observation of Resident #30 on 10/17/18 between 9:10 A.M. and 10:33 A.M. revealed the resident's personal safety alarm was not functioning. Observation of the alarm revealed the alarm base unit was attached properly to the wheel chair handle. Staff failed to attach the clip end of the pull cord to Resident #30's clothing; the clip was attached to the back of the wheelchair. In addition, the opposite end of the pull cord was viewed laying on the floor and was failed to be attached to the alarm base. Interview with State Tested Nursing Aide #400 on 10/17/18 at 10:36 A.M. verified Resident #30's PSA was not properly attached and failed to function properly. Review of the facility policy titled Alarms - Personal Monitoring, dated 07/13/07, revealed personal monitoring alarms will be checked every shift when in use for placement and function. This would include all types of alarms including but not limited to chair alarms, bed alarms, personal body alarms, motion detectors and wanderguards. 365155 Page 5 of 8 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

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, staff interview, and review of a facility policy, the facility failed to monitor residents taking antipsychotic medications for possible side effects. This affected two residents (#40 and #67) of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: 1. Medical record review revealed Resident #40 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, delusional disorder, and anxiety. Review of the resident's most recent plan of care revealed the resident was at risk for complications related to the administration of antipsychotic medication. Interventions included to complete an Abnormal Involuntary Movement Scale (AIMS) (a rating scale designed to measure involuntary movements known as tardive dyskinesia (TD) in residents receiving antipsychotic medications) assessment and report any changes to the physician. Review of a physician order, dated 02/28/18, revealed the resident was ordered Seroquel (antipsychotic medication) 25 milligrams (mg.) twice a day for a delusional disorder. Review of Resident #40's assessments revealed an AIMS assessment was completed on 02/14/18. No more recent assessment was found. 2. Medical record review revealed Resident #67 admitted to the facility on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, anxiety, and delusional disorder. Review of the resident's most recent plan of care revealed the resident was at risk for complications related to the administration of antipsychotic medication. Interventions included to complete an AIMS assessment and report any changes to the physician. Review of a physician order dated 02/28/18, revealed the resident was ordered Seroquel 25 mg. at bed time for a delusional disorder. Review of Resident #67's assessments revealed an AIMS assessment was completed on 02/14/18. No more recent assessment was found. Interview on 10/18/18 at 9:46 A.M., the Director of Nursing (DON) revealed all resident's that received antipsychotic medications were to have an AIMS assessment done, at minimum, every six months. The DON verified the last AIMS assessment completed for Resident #40 and Resident #67 was eight months ago, on 02/14/18. Review of a facility policy titled, Abnormal Involuntary Movement Scale (AIMS), dated 05/24/16, revealed the assessment was to be completed for all residents with orders for antipsychotic medications. Further review revealed the assessment was to be completed every six months and if the resident had a significant change. 365155 Page 6 of 8 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident's advanced directive wishes were accurate and placed in the resident's charts. This affected two (Resident #19 and #63) of 24 residents reviewed for advanced directives. The facility census was 84. Findings include: 1. Medical record review revealed Resident #19 admitted to the facility on [DATE]. Diagnoses included unspecified dementia. Review of a physician's orders, dated [DATE], revealed the advanced directive wishes for Resident #19 was to be a full code which meant he/she wished to have cardiopulmonary resuscitation (CPR) performed if needed. Review of the resident's most recent plan of care revealed the resident's advanced directive wishes were to be a full code and have CPR performed if needed. Review of a social service progress noted, dated [DATE], revealed a quarterly assessment was completed for Resident #19 and the resident's advanced directive was full code. Review of the resident's electronic health record (EHR) revealed the residents advanced directive was full code. Further review of the resident's paper chart revealed an advanced directive form dated [DATE] and signed by the residents representative. The form indicated Resident #19's advanced directive was changed to Do Not Resuscitate, Comfort Care (DNRCC) which meant CPR was not to be performed if the resident went into cardio and or pulmonary arrest. The form was also signed by the physician's Nurse Practitioner (NP). 2. Medical record review revealed Resident #63 admitted to the facility on [DATE]. Diagnoses included epilepsy and vascular dementia. Review of the resident's electronic health record (EHR) revealed no advanced directive listed. Further review of the resident's paper chart revealed a full code advanced directive form. Interview on [DATE], at 4:06 P.M., the Director of Nursing (DON) revealed all resident's advanced directive wishes were placed in the resident's paper chart and EHR on admission. The DON revealed the advanced directive, located in the paper chart and the EHR, were to be the same. The DON verified the advanced directive in Resident #19's EHR was full code and the advanced directive in the paper chart was DNRCC. The DON further revealed he had no knowledge the resident's representative changed the advance directive on [DATE]. The DON further verified no advanced directive was placed in Resident #63's EHR. The DON revealed the admitting nurse must of put the order wrong into the computer for Resident #63. Review of a facility policy titled, Resident's Rights: Treatment and Advanced Directives, dated [DATE], revealed each resident had the right to formulate an Advanced Directive and to accept for refuse medical statement. Further review revealed, upon admission, the facility would interview each resident to determine whether or not the resident had executed an advanced directive and a copy of the 365155 Page 7 of 8 365155 10/18/2018 Avon Place Healthcare Center 32900 Detroit Rd Avon, OH 44011

F 0842 residents advanced directive was to be placed in the medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365155 Page 8 of 8