Health inspection·March 21, 2024

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents Pre-admission Screening and Resident Review (PASARRs) were completed accurately and updated when a new diagnosis was identified. This affected four (#01, #13, #31 and #35) of the five residents reviewed for PASARRs. The facility census was 36. Findings include: 1) Review of the medical record for Resident #01 revealed an admission date of 04/12/17. Diagnoses included schizoaffective disorder, paranoid schizophrenia, personality disorder, depression, and anxiety. Review of the PASARR dated 12/12/22 for Resident #01, revealed mood disorder, and schizophrenia were listed for the resident. Personality disorder was not documented. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. 2) Review of the medical record for Resident #13 revealed an admission date of 09/10/21. Diagnoses included depression, chronic pulmonary disease, dementia, schizoaffective disorder bipolar type, anxiety, suicidal ideations, and cognitive impairments. Review of the PASARR dated 03/17/21 for Resident #13, revealed mood disorder, panic disorder and alcohol abuse were listed. Schizophrenia or other psychotic disorders were not documented for the resident's diagnosis of schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #13 was cognitively intact with a BIMS of 15. 3) Review of the medical record for Resident #31 revealed an admission date of 08/07/23. Diagnoses included dementia, bipolar disorder, spinal stenosis, unspecified psychosis, and chronic obstructive pulmonary disease. Review of the PASARR completed 07/23/23 for Resident #31 revealed the resident was documented to have schizophrenia and a mood disorder. Other psychotic disorders were not marked. Review of the MDS assessment dated [DATE] revealed Resident #31 was cognitively intact with a BIMS Page 1 of 9 365323 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

F 0646 of 15. Level of Harm - Minimal harm or potential for actual harm 4) Review of the medical record for Resident #35 revealed an admission date of 08/29/23. Diagnoses included unspecified dementia, schizotypal disorder, depressive disorder, lack of coordination and altered mental status. Residents Affected - Some Review of the PASARR dated 03/17/21 for Resident #35, revealed no dementia or mental disorders were listed. The Dementia section was marked no, and mental disorders were not selected. Review of the MDS assessment dated [DATE] revealed Resident #35 was cognitively impaired with a BIMS of 12. Interview on 03/20/24 at 11:03 A.M. with Social Services Director (SSD) #201 confirmed the facility staff discuss changes in diagnoses and discuss when a new PASARR was needed. SSD #201 confirmed the PASARR for Resident #01 did not have personality disorder documented, Resident #13 had diagnosis of Schizoaffective disorder and confirmed the diagnosis was not included on the PASARR, Resident #31 did not have a diagnosis of schizophrenia but had it marked on the PASARR and also had a diagnosis of unspecified psychosis which was not identified on the PASARR under other psychotic disorder and Resident #35 had a diagnosis of dementia which was not identified on the PASARR and a diagnosis of schizotypal disorder and depression which were not identified on the PASARR. Review of facility policy titled, PASRR Completion Policy undated, revealed the Administrator would designate a staff member to ensure PASARR was done on all potential residents. The policy did not state a process for ensuring documentation was updated from a change in diagnosis or to ensure accuracy. 365323 Page 2 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to ensure a resident was offered and assisted with showers per the resident's preference and according to the shower schedule. This affected one (#31) resident of two residents reviewed for activities of daily living (ADL) care. The facility census was 36. Residents Affected - Few Findings include: Review of the medical record for Resident #31 revealed an admission date of 08/07/23. Diagnoses included dementia, bipolar disorder, spinal stenosis, unspecified psychosis, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and required set up and clean up assistance with bathing. Review of the paper shower sheets from 02/01/24 to 03/20/24 for Resident #31 revealed there was only documented evidence of a shower/bathing being provided on 02/02/24, 02/27/24, 03/12/24 and 03/19/24. Review of the shower schedule for Resident #31, revealed showers should have been offered/provided included Tuesdays and Fridays on 02/02/24, 02/06/24, 02/09/24, 02/13/24, 02/16/24, 02/20/24, 02/23/24, 02/27/24, 03/01/24, 03/05/24, 03/08/24, 03/12/24, 03/15/24, and 03/19/24. Review of the bathing tasks section in the electronic medical record for Resident #31 revealed from 02/19/24 to 03/20/24, baths/showers were only documented as being provided on 03/05/24, 03/08/24 and 03/12/24. It was documented supervision assistance with oversite help only was provided. Review of the plan of care dated 03/07/24 for Resident #31 revealed the resident had an ADL care performance deficit and required set up and clean-up assistance with showering. Interview on 03/19/24 at 8:58 A.M. with Resident #31 revealed she was not receiving showers per her preference and on her scheduled dates. Resident #31 revealed she regularly missed showers and revealed it would get so late in the day, and her showers got missed due to staff being busy. Resident #31 reported she would prefer them earlier in the day during the first shift. Resident #31 reported she typically misses about one shower weekly. Interview on 03/21/24 at 9:00 A.M. with State Tested Nurses Assistants (STNAs) #207 and #208 revealed shower sheets were to be filled out for every shower including if/when a resident refused. STNA's #207 and #208 revealed shower sheets were placed into a binder and then collected almost daily by the medical records staff. Interview on 03/21/24 at 12:50 P.M. with Director of Nursing (DON) confirmed Resident #31 only had documented showers on 02/02/24, 02/27/24, 03/12/24 and 03/19/24. The DON reported the facility had a process to audit the shower sheets weekly and revealed no knowledge of the missing 10 shower sheets for Resident #31. 365323 Page 3 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/21/24 at 1:15 P.M. with the Administrator and DON confirmed they only had four shower sheets to provide for February and March 2024 and also confirmed there were three documented showers in the tasks section of the electronic medical record with one documented on both the electronic record and on the shower sheet for 03/12/24. Review of facility policy titled, Bath, Shower undated, revealed the purpose was to promote cleanliness, promote comfort and observe resident skin. The documentation required for showers includes date and time shower was provided, names of staff who assisted, supervisor shall be notified if resident refuses a shower. 365323 Page 4 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff interview, policy review and manufacturer instruction review, the facility failed to accurately complete insulin pen administration which resulted in a significant medication error. This affected one (#04) of the two residents observed for insulin administration. The facility identified nine (#03, #05, #18, #25, #26, #32, #33, and #35) residents who received insulin pen injections. The total facility census was 36. Residents Affected - Few Findings Include: Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, pure hyperglycemia, and schizoaffective disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04, revealed the resident was cognitively intact and the resident received injections and insulin on seven days of the review period. Review of the physician's orders dated 01/22/24 for Resident #04, revealed the resident was ordered to receive Basaglar KwikPen injector (long-acting insulin) 100 units/milliliter (mL), inject 20 units subcutaneously in the morning and 40 units subcutaneously at bedtime for diabetes. Observation of the medication administration on 03/18/24 at 6:39 P.M. for Resident #04 and performed by Registered Nurse (RN) #258 revealed, RN #258 obtained the Basaglar KwikPen from the medication cart, placed the disposable needle on the pen, and dialed the dose to 40 units. RN #258 was observed to administer the medication to Resident #04 in the resident's abdomen as per standard. Observation revealed RN #258 did not prime the insulin pen prior to the administration. During an interview with RN #258 on 03/18/24 at 6:50 P.M., the Surveyor questioned if RN #258 did anything to the Basaglar KwikPen after putting the disposable needle on the pen and prior to dialing up the ordered 40-unit dose and RN #258 replied no, you just have to dial up the dose and administer it to the resident. RN #258 verified she did not prime the Basaglar KwikPen prior to administering the insulin. Review of the September 2014 facility policy titled Insulin Administration revealed the purpose was to provide guidelines for the safe administration of insulin to residents with diabetes. The instructions included the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of manufacturer Basaglar KwikPen instructions for use revealed in step six included Priming the KwikPen. Prime the KwikPen before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps six to eight, but not more 365323 Page 5 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

F 0760 than four times. If you still do not see insulin, change the needle, and repeat the priming steps six to eight. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365323 Page 6 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interview, review of portion size documents and review of the facility policy, the facility failed to ensure the recipes for pureed foods were followed to ensure nutritional value. This had the potential to affect four (#01, #07, #10, #20) of the four residents who received pureed diets. The facility census was 54. Residents Affected - Some Findings include: Observation of [NAME] # 220 preparing puree meals on 03/20/24 at 11:15 A.M. revealed [NAME] #225 added water and bread to make the pureed chicken patty and did not add any chicken base. Interview with [NAME] #220 at the same time verified she always used water to put in the pureed foods and does not follow a recipe. Interview with Dietary Manager (DM)#285 on 03/20/24 at 11:20 A.M. verified they always use water to do their pureed foods. DM #285 reported the facility did not follow a specific recipe for pureed foods and this was the way she had been trained. Interview with Registered Dietitian Nutritionist, Licensed Dietitian #400 on 03/20/24 at 3:45 P.M. verified the DM#285 and the cook should be following the recipes for all meals. Review of the facility documents for sandwich chicken breaded pureed, revealed the portion size to be one each chicken breast fritter, a chicken base, hot water, food thickener and pureed bread. Review of the facility policy titled Nutrient Retention of Foods dated 04/07 revealed the facility will endeavor to prepare and serve foods in such a manner as to conserve the nutritive value of foods. Supervisors will instruct the cooks to prepare food in accordance with guidelines to minimize nutrient loss. 365323 Page 7 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

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 observation, staff interview, medical record review, facility policy review and manufacturer instructions review, the facility failed to discard the disposable needle off an insulin pen in a safe and sanitary manner. This affected one (#4) of two residents observed for insulin administration. The facility also failed to prepare an insulin pen injection in a sanitary manner. This affected one (#05) of two residents observed for insulin administration. The facility identified nine (#03, #18, #25, #26, #32, #33, and #35) residents who received insulin injections. The facility census was 36. Residents Affected - Few Findings Include: 1) Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, pure hyperglycemia, and schizoaffective disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04, revealed the resident was cognitively intact and the resident received injections and insulin on seven days of the review period. Review of the physician's orders dated 01/22/24 for Resident #04, revealed the resident was ordered to receive Basaglar KwikPen pen-injector (long-acting insulin) 100 units/milliliter (mL), inject 20 units subcutaneously in the morning and 40 units subcutaneously at bedtime for diabetes. Observation of medication administration on 03/18/24 at 6:39 P.M. for Resident #04 and performed by Registered Nurse (RN) #258, revealed RN #258 retrieved the Basaglar KwikPen from the medication cart, placed the disposable needle on the pen, and dialed the dose to 40 units. RN #258 was observed to administer the medication to Resident #04 in her abdomen as per standard. RN #258 was observed to remove the disposable needle off the insulin pen and place it in her soiled gloves and discard the gloves and the disposable needle in the trash can next to Resident #04's bed. As the nurse and Surveyor were exiting the resident's room, RN #258 reported the needle retracts after the injection so it could be disposed of in a regular trash can. Interview with RN #258 on 03/18/24 at 6:50 P.M., verified the used insulin pen disposable needle was discarded in the regular trash can and not placed in a sharp's container. Review of the policy titled Sharps Disposal revised January 2012, revealed the facility shall discard contaminated sharps into designated containers. Staff will discard them immediately or as soon as feasible into designated containers. Review of the Basaglar KwikPen manufacturer instructions revealed when disposing of the pens and needles, put the used needles in a Food and Drug Administration (FDA) cleared sharps disposal container right away after use and do not throw away (dispose of) loose needles in a house hold trash. 2) Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, anxiety, and retention of urine. Review of the quarterly MDS assessment dated [DATE] for Resident #05, revealed the resident was 365323 Page 8 of 9 365323 03/21/2024 Marion Pointe 409 Bellfontaine Avenue Marion, OH 43302

F 0880 cognitively intact and the resident received injections and insulin seven days of the review period. Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders dated 11/13/23 for Resident #05, revealed the resident was ordered to receive Insulin Glargine /Lantus (long-acting insulin) 100 units/mL to inject 30 unit subcutaneously at bedtime for diabetes. Residents Affected - Few Observation of medication administration for Resident #05 on 03/18/24 at 8:34 P.M. by Licensed Practical Nurse (LPN) #215 revealed the nurse retrieved the insulin pen from the medication cart, removed the pen cap, placed a disposable needle on the pen, primed the pen with two units of insulin, and then dialed up the 30-unit dose for the Resident. LPN #215 was observed to administer the dose to the resident as per standard and discarded her disposable needle in the sharp's container on her medication cart after removing her gloves and performing hand hygiene. Observation revealed LPN #215 did not cleanse the rubber seal on the insulin pen prior to attaching the disposable needle. Interview with LPN #215 on 03/18/24 at 8:38 P.M. verified she did not cleanse the rubber seal on the insulin pen prior to placing the disposable needle. LPN #215 reported she did not need to clean the rubber seal because the pen had a cover over it as it was being stored in the medication cart. Review of the September 2014 facility policy titled Insulin Administration revealed the purpose was to provide guidelines for the safe administration of insulin to residents with diabetes. The instructions and steps in the procedures included disinfecting the top of the insulin container with an alcohol prep. Review of the insulin Glargine (Lantus Solostar pen) manufacturer instructions revealed wipe the pen tip (rubber seal) with an alcohol swab then remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on the to pen. 365323 Page 9 of 9