Health inspection·August 1, 2019

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation, resident interview, and staff interview, the facility failed to ensure a list of pertinent state agencies and advocacy groups and the complaint hotline were posted in the facility. This had the potential to affect all 59 residents residing in the facility. Findings include: Interview with a confidential resident on 07/30/19 at 1:05 P.M., revealed he was unaware of how to file a complaint and where the state agency contact information was located. Observation throughout the facility on 08/01/19 at 10:00 A.M., revealed there were no postings of the complaint hotline or State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Interview with the Administrator on 08/01/19 at 10:00 A.M., verified there were no postings of the complaint hotline or State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Page 1 of 10 365221 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately assess antidepressant use on a resident's comprehensive admission Minimum Data Set (MDS) assessment. This affected one resident (Resident #25) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of the medical record for Resident #25 revealed an admission date of 05/21/19 with diagnoses including but not limited to end stage renal disease, hypertension, anxiety, and depression. Review of physician orders dated July 2019 revealed Resident #25 had an order dated 05/21/19 for an antidepressant medication Prozac daily for depression. Review of medication administration record dated May 2019 revealed Resident #25 received an antidepressant medication everyday from 05/23/19 through 05/27/19 and from 05/29/19 through 05/31/19. Review of admission minimum data set (MDS) dated [DATE] revealed Resident #25 was cognitively intact and received no antidepressant medication. Interview was conducted on 08/01/19 at 2:10 P.M., with Licensed Practical Nurse (LPN) #100 and she verified antidepressant medication was not coded on admission MDS for Resident #25 and Resident #25 did receive antidepressant medication during May 2019. 365221 Page 2 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

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 observation, resident record review, and staff interview, the facility failed to ensure a complete Long Term Care Minimum Data Set (MDS) 3.0 (a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment was completed. This affected one resident (Resident #4) of 15 resident records reviewed. Residents Affected - Few Findings Include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, bipolar disorder, depression and schizophrenia. The physician's orders included Prolixin 2.5 milligrams (mg) daily for schizophrenia. Review of the annual MDS 3.0 assessment completed on 04/28/19 revealed Section C (cognitive assessment), Section D (mood assessment), and Section F (personal preferences) was not completed for Resident #4. A psychoactive medical evaluation completed on 05/02/19 identified Prolixin was used for the diagnoses of schizophrenia. Behaviors identified on the evaluation included aggression, inappropriate responses, unwarranted suspiciousness, delusions and paranoia. A physician progress noted dated June 2019 indicated Resident #4 continued to have symptoms but was reasonably stable on Prolixin. During an interview with Licensed Practical Nurse (LPN) #100 on 08/01/19 at 1:05 P.M., verified she completed the MDS 3.0 for the facility. LPN #100 confirmed section C, D, and F of Resident #4 MDS 3.0 dated 04/28/19 was not completed. LPN #100 stated no reassessment had been completed for Resident #4. Review of the facility policy Comprehensive Assessment dated 09/2010 revealed the facility was not in compliance with their policy. 365221 Page 3 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to follow up on the assistive hearing device needs for one (Resident #17) of one resident reviewed for hearing services. The facility census was 59. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 01/04/08 with diagnoses including intellectual disabilities (unspecified), anxiety disorder, dysphagia, and schizophrenia. Review of the Certificate of Medical Necessity dated 12/07/18 revealed Resident #17 had a hearing test on 09/13/18 with a moderately severe hearing loss noted to the right and left ears and digital hearing aids prescribed to provide optimal sound quality to be programmed to specifically meet the need of a hearing loss configuration. Review of Resident #17's care plan dated 01/13/19 revealed a category of Cognition/Neurology and resident had a hearing loss and hearing aids with an intervention of resident chose when to wear them and have been lost or misplaced multiple times. Review of a receipt dated 02/19/19 revealed hearing aids were delivered on 02/19/19 for Resident #17. Review of the physician's progress notes dated 02/20/19 revealed Resident #17 had hearing aids for decreased hearing and was wearing them and liked them. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and independent in mobility, transfers, dressing, eating, hygiene, toileting without the use of any assistive devices. Interview with Resident #17 on 07/29/19 at 2:18 P.M. revealed the resident wanted hearing aides and Resident #17 stated she informed the facility but the facility did not help arrange an appointment. Interview on 08/01/19 at 10:20 A.M., with Licensed Practical Nurse (LPN) #46 revealed Resident #17 had old hearing aids for two days and broke them. LPN #46 stated there was only one Resident #17's hearing aids in the medication cart. LPN #46 stated she was unsure of the date the hearing aids were broke and Resident #17 had an appointment with the audiologist for replacement hearing aids. Interview with Scheduler #22 and Medical Records Coordinator #1 on 08/01/19 at 10:29 A.M., verified there was not a follow up appointment scheduled for Resident #17 for replacement hearing aids as they were unaware she needed or utilized hearing aids. Medical Records Coordinator #1 further stated that broken devices are brought to her and she had not received hearing aids or the need for replacement hearing aids for Resident #17. Medical Records Coordinator #1 stated the audiologist comes to the facility every three months and was at the facility in June, but Resident #17 was not put on the list for follow up. 365221 Page 4 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

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, staff interview and document review, the facility failed to ensure a resident with oxygen had the nasal cannula changed and dated weekly. This affected one (Resident #16) of two Residents reviewed for oxygen care. This had the potential to affect 15 (Resident #2, #12, #15, #16, #17, #21, #25, #28, #34, #37, #44, #48, #52, #256, and #308,) facility identified residents on oxygen. The facility census was 59. Residents Affected - Few Findings include: Record review of Resident #16 revealed an admission date of 5/10/19 with pertinent diagnosis of: acute and chronic respiratory failure, chronic obstructive pulmonary disease, diabetes mellitus, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and used oxygen while in the facility. Observation on 07/31/19 at 8:25 A.M., revealed an undated oxygen nasal cannula tubing was noted in Resident #16's room. The resident stated she did not know when it was last changed. Interview with the Director of Nursing (DON) on 07/31/19 at 8:36 A.M., verified the oxygen nasal cannula was not dated for Resident #16. Review of a facility policy titled Respiratory Therapy Prevention of Infection, dated 11/01/11, revealed to change the oxygen cannula and tubing every seven days or as needed and store in a plastic bag marked with the date. 365221 Page 5 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interview, the facility failed to have a policy or procedure for time frames in the medication regimen review and steps when an irregularity required immediate action and failed to ensure a residents pharmacy recommendations were not addressed for over a month. This affected one Resident (#32) of five Residents reviewed for medications and had the potential to affect all residents who had monthly pharmacy medication reviews. The facility census was 59. Findings include: 1. Interview with the Director of Nursing (DON) on 08/01/19 at 10:18 A.M. revealed she would get the facility policy on time frames in the medication regimen review and steps when an irregularity requires immediate action. Review of a facility policy titled Medication Utilization and Prescribing dated 09/01/12 revealed no information concerning time frames in the medication regimen review and steps when an irregularity required immediate action. Interview with the Administrator on 08/01/19 at 12:53 P.M., verified the policy did not address the time frames in the medication regimen review and steps when an irregularity required immediate action. The Administrator verified that was the only policy on medication regimen review. 2. Record review of Resident #32 revealed an admission date of 04/06/19 with pertinent diagnoses of: gangrene, acute osteomyelitis of the left ankle and foot, morbid obesity, diabetes mellitus type two, obstructive sleep apnea, nicotine dependence, and venous insufficiency. Review of the pharmacy consultation report dated 04/11/19 revealed three recommendations including a recommendation to discontinue receiving aspirin since the resident was receiving heparin (an anticoagulant medication). A recommendation for a diagnosis for ability (an antipsychotic medication) and a recommendation to discontinue two medications that used together increase edema, pregabalin (an anticonvulsant) and pioglitazone (antidiabetic medication). Review of the the pharmacy consultation reports dated 04/11/19 revealed they were not answered until 05/17/19 and 05/18/19. Interview with the Director of Nursing (DON) on 08/01/19 at 10:18 A.M. verified the pharmacy recommendations were not addressed for over a month and that she was unsure of why they were not addressed. 365221 Page 6 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

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, observation and staff interview, the facility failed to monitor behaviors for one resident (Resident #4) who was receiving antipsychotic medications of six residents were reviewed for unnecessary medications. The facility census was 59. Findings Include: Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, bipolar disorder, depression and schizophrenia. The physician's orders included Prolixin 2.5 milligrams (mg) daily for schizophrenia. The plan of care dated 10/12/17 indicated Resident #4 received an antipsychotic medication and to monitor behavior symptoms with the goal the resident would not resist care. A Psychoactive medical evaluation completed on 05/02/19 identified Prolixin was used for the diagnosis of schizophrenia. Behaviors identified on the evaluation included aggression, inappropriate responses, unwarranted suspiciousness, delusions and paranoia. A physician progress note dated 06/2019 indicated Resident #4 continued to have symptoms but was reasonably stable on Prolixin. During an interview on 08/01/19 at 10:08 A.M., with Licensed Practical Nurse (LPN) #48 reported had care for Resident #4 for quite a few years. LPN #48 reported Resident #4 had improved and although continued to have behaviors (signing meal ticket as someone else, sudden mood swings, asking for specific number of ice cubes and becoming upset if not as requested) they had diminished greatly. On 08/01/19 at 10:19 A.M., the Director of Nurses (DON) reported no behavior monitoring for Resident #4 for the past six months. The DON stated the resident had greatly improved and they were no longer monitoring. The DON stated he would continue to do 'strange things' like asking for three sherbet and four ice creams, requests certain number of ice cubes, etc. On 08/01/19 at 10:47 A.M., the DON and Corporate Registered Nurse (RN)#125 verified all staff were aware of Resident #4 behaviors and would only respond/document in the medical record if the behavior was elevated. The facility reported they did not have a policy for behavior monitoring. 365221 Page 7 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and facilities policy review, the facility failed to follow infection control practices with a resident on contact precautions. This affected one (Resident #13) of two residents reviewed on precautions. The facility census was 59. Residents Affected - Few Findings include: Review of the medical record for Resident #13 revealed an admission date of 01/16/19 with diagnoses including but not limited to traumatic brain injury, seizures, and clostridium difficile (c-diff). Review of physician orders dated 06/28/19 revealed an antibiotic order and to place Resident #13 under contact precautions. Review of physician progress note dated 07/17/19 revealed Resident #13 was being treated for c-diff colitis. Observation conducted on 07/29/19 at 11:47 A.M., revealed State Tested Nursing Assistant (STNA) #56 went into Resident #13's room with clean bed linens in hand and made his bed. STNA #56 did not wash hands upon entering and exiting room and did not have on any personal protective equipment when making Resident #13's bed. STNA #56 then took in Resident #13's lunch tray and sat it on his bed on top of clean linens and she then sat down on top of Resident #13's bed with no personal protective gear on. Resident #13 was sitting up in a specialized power chair at the bedside. STNA #56 then proceeded to feed Resident #13 while she sat on his bed and left his lunch tray also sit on the bed as she was giving him bites of food. Resident #13 had personal protective gear including gown and gloves hanging on the outside of his door. Interview was conducted on 07/29/19 at 11:59 A.M., with STNA #56 who stated Resident #13 was on contact precautions for c-diff and the only time they have to wear gloves and gown was when he had a bowel movement and stated Resident #13 was good at telling them when he went to the bathroom. She verified she made his bed, sat on his bed, and fed him with no personal protective gear on. Review of nurses notes dated 07/29/19 at 4:00 P.M., revealed Resident #13's contact precautions were discontinued per physicians orders. Interview was conducted on 07/31/19 at 9:00 A.M., with the Director of Nursing and she stated staff was to wear personal protective gear when a resident was on contact precautions for c-diff any time care was being done for that resident. She stated changing a residents bed included care being done and personal protective gear to be worn. She stated staff should not be sitting on residents bed when they are on isolation with no protective gear on. She stated Resident #13's contact isolation was discontinued on 07/29/19. Interview was conducted on 07/31/19 at 9:10 A.M., Registered Nurse (RN) #36 stated she called the physician on 07/29/19 at 4:00 P.M. and obtained an order to discontinue Resident #13's precautions. She verified Resident #13 was still on contact isolation at 11:47 A.M. on 07/29/19. Review of the undated facility policy titled Clostridium Difficile Policy revealed preventative measures will be taken to prevent the occurrence of clostridium difficile infections among residents and precautions will be taken while caring for a resident with c-diff to prevent the transmission of 365221 Page 8 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few c-diff to others. The primary reservoirs for c-diff are infected people and surfaces. Spores can persists on resident-care items and surfaces for several months and are resistant to common cleaning and disinfection methods. Residents with c-diff will be placed on contact precautions. A health care worker will wear gloves and gowns when providing resident care for a resident with c-diff. Visitors will be encouraged to wear gowns and gloves and instructed on proper hand hygiene. Gloves will be used when caring for residents with c-diff infection, washing hands with soap and water upon exiting the room and strict adherence to hand hygiene in general is considered best practice. 365221 Page 9 of 10 365221 08/01/2019 Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and facilities policy review, the facility failed to provide a clean and well maintained resident smoking area that was free from used smoking materials and failed to keep ash trays emptied and in good condition. This had the potential to affect 20 residents ( Resident #16, #28, #256, #40, #44, #43, #39, #5, #307, #257, #13, #258, #29, #22, #306, #305, #255, #41, #34, and #37) in the facility who are smokers. The facility census was 59. Findings include : Observation was conducted on 07/29/19 at 11:22 A.M., of the resident smoking area and noted one smoking receptacle with no lid that contained multiple cigarette butts, ashes, a plastic bag, a pop can, and empty packs of cigarettes. Another smoking receptacle with half of a lid and contained cigarette butts, ashes, a paper coffee cup, and packs of empty cigarettes. There was one trash can that contained a lid and noted cigarette butts and ashes and numerous trash. There was one ash tray that sat on table that was noted to be in poor repair with the sides rusted open exposing ashes and cigarettes. There was multiple cigarette butts laying on the ground all around the smoking area. Interview was conducted on 07/29/19 at 11:42 A.M. with Maintenance Director #222 and he verified there was broken cigarette receptacles and ash trays and that they contained paper products and stated he had been fighting this for years. He stated they ordered all new ash trays and receptacles last year and and he would let Administrator know they needed new ones again. Review of facility policy titled Resident Smoking Policy and Procedure, dated 2017 revealed the facility will maintain an environment that remains as free of accident hazards as is possible, and will ensure that each resident receives adequate supervision and assistance to prevent accidents. Ash trays shall be provided in all designated resident smoking areas. These ash trays shall be either self-closing or have a cigarette island in the middle. Ash trays, waste baskets, or containers where burnable materials are placed shall not be made of materials which are flammable, combustible, or capable of generating quantities of smoke. 365221 Page 10 of 10