Health inspection·August 5, 2021

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 review of medical records, staff interviews, and review of facility policy, the facility failed to ensure as-needed anti-anxiety medication had a rationale for continued use past 14 days for one (#18) of six residents reviewed for unnecessary medications. The facility identified 10 residents who were prescribed anti-anxiety medications. The census was 35. Findings include: Review of Resident #18's medical record revealed she admitted to the facility 09/29/20. Her diagnoses included dementia with behavioral disturbance and anxiety. Review of her Minimum Data Set (MDS) assessment dated [DATE], revealed she had a severe cognitive impairment and exhibited behaviors that significantly impacted social interactions. She was dependent on staff for all activities-of-daily-living. She received anti-anxiety medications daily. Review of a physician order dated 06/23/21 revealed Resident #18 was prescribed lorazepam (an anti-anxiety medication) one milligram (mg) each hour as needed for anxiety. Further review of Resident #18's physician orders and medical record lacked evidence a physician documented a rationale for extended use of as-needed anti-anxiety medications. Review of Resident #18's Medication Administration Record (MAR) for June 2021 revealed she received as-needed (PRN) anti-anxiety medications twice 6/23/21, once 6/24/21, 6/28/21, and 06/29/21. Review of Resident #18's Medication Administration Record (MAR) for July 2021 revealed she received as-needed (PRN) anti-anxiety medications once 07/02/21, 07/04/21; twice 07/05/21; once 07/06/21; twice 07/10/21; once 07/11/21-07/13/21, 07/23/21, 07/25/21-07/26/21, 07/30/21; and in August 2021, 08/02/21. Interview on 08/04/21 at 11:29 A.M. with the Director of Nursing (DON) confirmed Resident #18 has received PRN anti-anxiety medication since 06/23/21 without the prescribing physician's rationale for extended use. DON stated the facility lacked a policy that guided staff on the use of anti-anxiety medications. Page 1 of 2 365331 365331 08/05/2021 Shelby Pointe 100 Rogers Lane Shelby, OH 44875

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and policy review, the facility failed to ensure transmission-based precautions were implemented to prevent the spread of COVID-19. This affected one (#235) of two residents in the facility that were new admissions presumed COVID-19 positive. The facility identified no current positive COVID-19 residents. The census was 35. Residents Affected - Few Findings include: Review of the medical records for Resident #235 revealed an admission date of 07/29/21. Diagnosis included Schizoaffective, anxiety, major depression and borderline personality disorder. Review of the order Quarantine for 14 days due to COVID-19 Precautions upon admission due to no COVID Vaccine per Facility Protocol. Observation on 08/03/21 at 9:42 A.M., of Housekeeper #350 coming out of Resident #235's room wearing gloves, gown and mask, caring a large red biohazard bag. Housekeeper #350 proceeded to carry the biohazard bag through the dining room and through the hall to the laundry chute. Housekeeper #350 returned to Resident #235's room with same personal protective equipment (PPE) on, reentered room. At 9:49 A.M., the Housekeeper #350 came back out of the isolation room with another red biohazard bag and again carried it through the dining room and down the hall to the laundry chute, with same PPE on. Housekeeper #350 returned to Resident #235's room and reentered a second time. At 9:58 A.M., Housekeeper came out of Resident #235's room and removed PPE. Interview on 08/03/21 at 10:00 A.M., with Housekeeper #350 verified she did not remove her PPE when leaving an isolation room. Housekeeper #350 verified she should not be carrying a dirty laundry bag through the dining room and down the hall. Housekeeper #350 verified that Resident #235 was on isolation due to being a new admission. Interview on 08/03/21 at 10:30 A.M., with the Interim Director of Nursing (DON) verified when leaving an isolation room staff are to remove PPE prior to leaving the room. The Interim DON stated biohazard bags are not to be carried through the facility. Review of the undated policy titled Donning and Doffing PPE revealed all PPE is to be removed prior to leaving the resident room. The deficiency substantiates the allegations contained in Complaint Number OH0011859. 365331 Page 2 of 2