Health inspection·August 15, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #30's physician was notified of elevated blood glucose levels as ordered. This affected one resident (#30) of six residents reviewed for medication use. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included hemodialysis, right above knee amputation, diabetes mellitus and chronic kidney failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/05/19 revealed the resident's cognition was intact and she required extensive assistance of two or more staff members for bed mobility and transfers. Review of the resident's physician orders revealed the resident had an order for insulin, Novolog to be administered using a sliding scale before meals and at bed time. The parameters for administration included for a blood sugar of 341 to 400 to administer 12 units and notify the physician. Review of the blood sugar documentation for June 2019 revealed no evidence the physician was notified when the resident's blood sugar was between 341-400 on 06/09/19, 06/11/19, 06/12/19, 06/16/19, 06/18/19, 06/20/19, 06/27/19 and 06/29/19. Review of the blood sugar documentation for July 2019 revealed no evidence the physician was notified when the resident's blood sugar was between 341-400 on 07/09/19, 07/12/19, 07/13/19, 07/16/19, 07/17/19, 07/20/19, 07/22/19, 07/23/19, 07/25/19, 07/28/19, 07/29/19 and 07/30/19. Review of the blood sugar documentation from 08/01/19 through 08/14/19 revealed no evidence the physician was notified when the resident's blood sugar was between 341-400 on 08/04/19 and 08/06/19. Record review revealed there was no evidence of notification of the physician for any blood sugars between 341 to 400 for the the months of 04/2019 to 08/2019. Interview with the Director of Nursing (DON) on 08/14/19 at 3:10 P.M. revealed the facility had not been notifying the physician of the resident's blood sugars between 341 and 400 as ordered. Page 1 of 15 365342 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) forms dated after 06/08/19 had the correct Quality Improvement Organization (QIO) contact information. This affected five residents (#10, #15, #56, #57, and #105) of five residents reviewed who had been issued NOMNC forms after 06/08/19. Residents Affected - Some Findings include: Resident #10 was admitted to the facility under Medicare skilled services on 04/18/19 and was issued a last covered skilled Medicare date of 06/10/19. Resident #15 was admitted to the facility under Medicare skilled services on 04/30/19 and was issued a last covered skilled Medicare date of 06/27/19. Resident #56 was admitted to the facility on [DATE] and was issued a last covered skilled Medicare date of 06/28/19. Resident #57 was admitted to the facility on [DATE] and was issued a last covered skilled Medicare date of 07/28/19. Resident #105's latest admission to the facility was 08/02/19 and was issued a last covered skilled Medicare date of 08/06/19. Review of the facility NOMNC forms revealed the QIO information provided to residents included the name and contact information for Ohio Kepro. According to the Centers for Medicare and Medicaid Services website, cms.gov, the QIO changed to Livanta QIO on 06/08/19. Interview with Social Services Designee (SSD) #102 on 08/14/19 at 5:17 P.M. confirmed the facility NOMNC forms given to Resident #10, #15, #56, #57 and #105 did not have the correct QIO contact information. SSD #102 also confirmed the current blank NOMNC forms the facility provided did not have the correct QIO information. 365342 Page 2 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #32's room was maintained in an odor free manner. This affected one resident (#32) of three residents reviewed for physical environment. Findings include: Resident #32 was initially admitted on [DATE] and readmitted on [DATE] with a diagnosis including Alzheimer's Disease. Review of Resident #32's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required supervision with bed mobility, transfers, and toileting, and his cognition was severely impaired. Observation on 08/14/19 at 2:34 P.M. with Licensed Practical Nurse (LPN) #114 revealed Resident #32's bathroom had a strong pungent odor in the room. LPN #114 revealed Resident #32's restroom has had a smell because his roommate was incontinent. Interview on 08/15/19 at 9:39 A.M. with Resident #32's family member revealed the facility does not clean well, and that the family had to scrub Resident #32's room on 08/13/19 due to the odors. Resident #32's family member explained the bathroom has smelled for some time. 365342 Page 3 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

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 record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately completed for Resident #30 and Resident #43. This affected two residents (#30 and #43) of 14 residents whose MDS 3.0 assessments were reviewed. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included hemodialysis, right above knee amputation, diabetes and chronic kidney failure. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed her cognition was intact and she required extensive assistance of two or more staff members for bed mobility and transfers. Further review of the history and physical dated 06/28/19 from the hospital revealed the resident was on her power scooter coming out of the bathroom and she used her leg to kick the door open. She accidentally hit the power button on her scooter and her leg somehow got smashed/caught in her door which caused a fracture. Review of the MDS 3.0 assessment, dated 07/05/19 revealed it did not capture fracture. Interview with MDS Supervisor #122 on 08/15/19 at 1:30 P.M. verified the MDS 3.0 assessment completed on 07/05/19 was not accurate to reflect the resident's fracture. 2. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including major depression and insomnia. Review of Resident #43's orders and Medication Administration Records (MAR) dated 07/06/19 to 07/12/19 revealed the resident had received five doses Ramelteon 8 milligrams (mg) at bedtime for insomnia. The Ramelteon was discontinued on 07/11/19. There was no other evidence the resident had received any other type of hypnotics from 07/06/19 to 07/12/19. Review of Resident #43's 60-day MDS 3.0 assessment, dated 07/12/19 revealed the resident received seven days of hypnotics during the seven day look back period (07/06/19 to 07/12/10). Interview on 08/14/19 at 3:57 P.M., with Registered Nurse (RN) #122 verified the 60-day MDS was coded inaccurately and should have reflected the resident received five days not seven days of hypnotics. 365342 Page 4 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop and implement a comprehensive and individualized plan of care for Resident #28 related to suicidal ideation/self harm. This affected one resident (#28) of 14 residents whose care plans were reviewed. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic pain, scoliosis, osteoarthritis, Alzheimer's disease, major depression, anxiety,and kidney failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was intact. Review of the progress notes dated 08/09/2019 at 9:15 A.M. revealed the MDS nurse was informed by Social Worker (via telephone) and Nutritionist (at nurse's station) that Resident #28 was suicidal and stated he had a plan to jump in front of a car and it would happen very soon. Immediately after the phone call the Administrator was informed and the Director of Nursing was contacted. The MDS nurse reported to the resident's room for one on one observation. The resident was sleeping quietly upon arrival. Resident slept on and off but remained in bed the entire time. During the observation the resident woke and asked why are you here? This nurse informed the resident that she was keeping him company because he had stated he was going to hurt himself. Review of the ongoing entry in the progress notes revealed the resident continued to make self harm statements to staff and one on one care was provided. Review of the progress note, dated 08/10/2019 at 7:11 A.M. revealed the resident was on every 15 minute checks at that time. Review of Resident #28's plan of care revealed no care plan had been developed for suicidal ideations/self harm. Interview with MDS Supervisor #122 on 08/15/19 at 12:45 P.M. verified no plan of care for suicidal ideations had been developed for Resident #28 following the above identified behaviors. 365342 Page 5 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #32's fall prevention interventions were in place at all times to decrease the resident's risk of falls. This affected one resident (#32) of five residents reviewed for falls. Findings include: Record review revealed Resident #32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including abnormalities of gait and mobility, lack of coordination, abnormal posture, history of falling, right and left ankle contractures, and Alzheimer's Disease. Resident #32's physician orders dated 05/30/19 revealed he was to have a weight rollator in room to aid in mobility. Resident #32's current comprehensive care plan revealed the resident was at risk for falls. Interventions included for the resident to have non-skid socks or tennis shoes on when up ambulating and on 08/02/19 an intervention was added to place rollator beside chair and/or bed. Review of Resident #32's medical record revealed from 03/01/19 through 08/12/19 the resident sustained five falls. Review of Resident #32's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he required supervision with bed mobility, transfers, and toileting, and his cognition was severely impaired. On 08/12/19 at 12:01 P.M. Resident #32 was observed in his room revealed he was sitting in his recliner in room with his rollator walker out of reach across his room and he was not wearing non skid footwear. Licensed Practical Nurse (LPN) #133 confirmed Resident #32's rollator was out of reach and he was not wearing non skid footwear. Interview on 08/12/19 at 12:01 P.M. with LPN #133 revealed Resident #32 could get him self out of bed into his recliner and back into bed. 365342 Page 6 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such 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 and staff interview the facility failed to monitor Resident #30's hemodialysis access site. This affected one resident (#30) of one resident reviewed for hemodialysis. Residents Affected - Few Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included hemodialysis, right above knee amputation, diabetes and chronic kidney failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact and she required extensive assistance of two or more staff members for bed mobility and transfers. Review of the medical record revealed no evidence the facility staff were monitoring the resident's hemodialysis access site (a port to the left chest) for complications such as infection, redness or bleeding. On 08/14/19 at 4:34 P.M. interview with the Director of Nursing verified there was no evidence to support the resident's hemodialysis access site was being monitored. 365342 Page 7 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide routine medication to Resident #33 as ordered. This affected one resident (#33) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, obsessive-compulsive disorder, insomnia, anxiety disorder, psychosis, and chronic obstructive pulmonary disorder. Review of Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/08/19 revealed her cognition was intact. Review of Resident #32's physician progress note, dated 07/24/19 revealed Resident #33 was on Klonopin, an anti-anxiety medication 0.5 milligrams (mg) two times a day and one mg at bedtime. Staff noted the resident was very anxious and tended to perseverate over medical conditions. Resident #33 reported she was worried about upcoming colonoscopy and could not stop her racing thoughts. The Klonopin helped, but it was not enough. The plan was to increase her Klonopin to one mg three time a day. Review of Resident #33's physician's orders revealed on 07/24/19 the Klonopin was increased to one mg three times a day for psychotic disorder. Review of Resident #33's July 2019 Medication Administration Record (MAR) revealed she she did not receive the Klonopin as ordered on 07/25/19, 07/26/19 or 07/27/19. Review of Resident #33's Health Status Note, dated 07/25/19 revealed the nurse spoke with pharmacy related to a request for the resident's Klonopin script. Pharmacy sent communication to the physician on 07/24/19 to obtain script, and the nurse left a message for the physician to call the facility to follow up on script request. Interview on 08/13/19 at 10:43 A.M. with Resident #33 revealed she went three days without her Klonopin recently, and her anxiety was difficult to control. Interview on 08/13/19 at 3:48 A.M. with Licensed Practical Nurse (LPN) #133 revealed when the physician increased Resident #33's Klonopin on 07/24/19 he did not write a prescription, confirming Resident #33 was without her medication. LPN #133 revealed they had to go to the nurse practitioner to get the prescription. 365342 Page 8 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0791 Provide or obtain dental services for each resident. 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 and interview the facility failed to ensure timely dental services were provided to Resident #33. This affected one resident (#33) of two residents reviewed for dental care. Residents Affected - Few Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, obsessive-compulsive disorder, insomnia, anxiety disorder, psychosis, and chronic obstructive pulmonary disorder. Resident #33's comprehensive care plan for dental care, initiated 10/14/18, revealed the facility would observe for recommendations from dental consult and include the resident in her treatment plan. Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/08/19 revealed her cognition was intact. Review of Resident #33's psychosocial note, dated 07/12/19 revealed the resident was seen by dentist. Resident #33's psychosocial note, dated 07/18/19 revealed the resident's dentures came back on this day, and upon trying them out, the resident stated the dentures did not fit and were causing significant pain. The social worker called the dentist's office and informed them of the resident's complaints/concerns. The office stated they were going to be unable to make a visit back to the facility for quite some time. The office sent over an order for the resident to only wear dentures during meal times and to remove them between meals. Orders were passed on to the nurse. The resident stated that would be impossible due to the amount of pain and discomfort the dentures caused just by being in her mouth for a very short amount of time. The resident refused to wear them during meals. The note indicated the social worker would follow up with the dental office about alternate possibilities. Resident #33's psychosocial note, dated 08/07/19 revealed the social worker spoke with the dental office and the office stated the resident would be added to the schedule of their next visit to evaluate the realignment of her dentures. The date was to be determined. Interview on 08/12/19 at 10:44 A.M. with Resident #33 revealed her dentures were realigned, but they did not fit, and the facility indicated she would not been seen by the dentist for six months. Resident #33 indicated she could not eat without the dentures, so she chose soft food. The resident also revealed she did not like to go to activities because she could not wear her teeth. Resident #33 revealed the dentist would come to the facility if they had enough patients. Resident #33 was observed without any dentures in at the time of the interview. Interview on 08/13/19 at 1:40 P.M. with Social Services Director (SSD) #102 and Licensed Practical Nurse (LPN) #133 revealed Resident #33 was seen by the dentist on 07/12/19 to adjust her dentures. When the dentures were sent to the facility they did not fit properly with an order for nursing to glue them in. Resident #33 reported the dentures were painful, so she did not wear them. The facility notified the doctor, and the doctor ordered to encourage the resident to remove the dentures between meals. SSD #102 revealed she contacted the dental office on 07/18/19 and on 08/07/19 and the office 365342 Page 9 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated they had to find an appropriate date to come to the area the facility was in. LPN #133 revealed the dentist comes quarterly. Observation on 08/13/19 at 2:27 P.M. revealed Resident #33 was sitting in a chair near the common room where an activity was going to begin. An employee walked by the resident and asked her if she wanted to play bingo. Resident #33 shook her head no and pointed to her mouth with no teeth. 365342 Page 10 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

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 record review and interview the facility failed to ensure adequate doses of insulin were administered/documented for Resident #43 based on the physician orders for insulin administration. This affected one resident (#43) of five residents reviewed for medication use. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnosis including type two diabetes mellitus with long term use of insulin. Review of Resident #43's orders and Medication Administration Records (MAR) revealed the resident's blood sugar was to be checked before meals and at bedtime. The resident had an order for Lispro insulin which was to be administered based on sliding scale coverage. If the resident's blood sugar was between 200 and 400, staff were to divide the blood glucose by 30 and subtract 3 (to determine the amount of insulin to administer). Record review revealed the resident's blood glucose was greater than 200 69 times in July 2019 and 21 times in August 2019. There was no evidence staff documented the amount of insulin administered for the blood glucose levels that were over 200 during this time period. Interview on 08/14/19 at 3:32 P.M., with the Director of Nursing (DON) confirmed there was no evidence of the amount of insulin administered per the order if blood sugar was between 200-400 from 07/01/19 to 08/14/19 on the MAR. She confirmed there was one progress note, dated 08/04/19 as the resident's blood glucose was 505 and the nurse had to call the physician for orders. She verified there was no way to determine the resident received the correct dose of insulin during the reviewed time period. 365342 Page 11 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0881 Implement a program that monitors antibiotic use. 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 and interview the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent unnecessary/inappropriate use of antibiotics. This affected two residents (#5 and #43) of five residents reviewed for medication use. Residents Affected - Few Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including diabetes, mood disorder, Alzheimer's, intermittent explosive disorder, chronic pain and dementia. Review of Resident #5's progress notes revealed on 06/18/19 the resident was having (urinary)dribbling and a strong foul (urine) odor. The physician was contacted and new orders were received for a urine specimen to be sent for urinalysis and culture/sensitivity. The resident was straight cathed and 75 milliliters (ml) of dark yellow urine was returned. Review of Resident #5's urinalysis, dated 06/18/19 revealed the resident had negative leukocytes, blood, and few bacteria. The urine culture indicted mixed skin flora. No sensitivity was done. On 06/19/19 and 06/24/19 the physician was notified of the laboratory results and no new orders were given at this time. On 06/27/19 new orders were received to start the antibiotic, Macrobid 100 mg twice daily due to complaints of pain with urination. There was no evidence the resident met the criteria for antibiotic administration, the physician was notified the resident did not met criteria for antibiotic treatment or justification why the resident needed antibiotic treatment without meeting the criteria. Review of Resident #5's orders and Medication Administration Records (MAR) dated 06/27/19 to 07/06/19 revealed the resident received the antibiotic, Macrobid 100 milligrams (mg) one capsule by mouth twice daily for urinary tract infection. Review of Resident #5's McGeer criteria for infection surveillance checklist dated 06/29/19 indicted the resident did not met criteria for antibiotic. The resident did not have an indwelling catheter and did not met the #2 criteria. The #2 criteria included having at least one of the following: microbiologic criteria greater than or equal 10 cfu/ml of no more than two species of organisms in a voided urine sample or greater than or equal of 10 cfu/ml of any organism in a specimen collected by an in-and -out catheter. Interview on 08/15/19 at 12:20 P.M. with the Director of Nursing (DON) verified Resident #5 did not met criteria for antibiotic treatment for UTI. Interview on 08/15/19 at 9:08 A.M., with Physician #172 revealed it had been about a year ago when she received training on the antibiotic stewardship program. She was not aware which criteria the facility was currently using to ensure appropriateness of antibiotic use. 2. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, diabetes, depression, intermittent explosive disorder, Alzheimer's disease, insomnia, heart disease, pain and osteoporosis. 365342 Page 12 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0881 Level of Harm - Minimal harm or potential for actual harm Review of Resident #43's orders and MAR, dated 07/16/16 to 07/24/19 revealed the resident received Amoxicillin 500 mg three times a day for tooth infection. Review of Resident #43's McGeer criteria for infection surveillance checklist dated 07/16/19 revealed there was no evidence the resident met the criteria for antibiotic treatment. Residents Affected - Few Review of fax communication sheet dated 07/16/19 revealed social worker (SW) #102 faxed the dentist regarding Resident #43 having broken her front bottom tooth. The resident had dementia and seemed to be in pain per the nurse. The dentist requested the physician to prescribe an antibiotic for seven to 10 days and pain medication for five to seven days. Review of Resident #43's progress notes dated 07/09/19 to 07/17/19 revealed on 07/09/19 the resident frequently complained of hunger (I'm hungry). Snacks offered. Resident sits at table eating chips and fruit. On 07/16/19 the social worker was made aware by therapy that the resident's front, bottom tooth was broken. Therapy believed that some of the resident's behaviors (constantly asking for food or claiming to be hungry) might be due to symptoms stemming from the broken tooth. The dental office was notified, and new orders were received. Medicaid authorization was sent to the dental office. On 07/17/19 the resident was resting quietly in bed with eyes closed. Received new orders for the antibiotic, Amoxicillin 500 mg by mouth every eight hours for seven days for broken tooth. The resident's temperate was 98.2 degrees Fahrenheit. There was no evidence the physician saw/followed up with the resident 72 hours after the telephoning in the antibiotic. Interview on 08/14/19 at 5:02 P.M., with the DON verified the resident did not met antibiotic criteria and the dentist order the antibiotic prophylactic. She confirmed the resident did not have any documented evidence of fever or infected gums/tooth. She reported the resident still had not seen the dentist as of this time. She reported she was going to call the family and possibly send her to an outside dentist for treatment. Interview on 08/14/19 at 5:17 P.M., with SW #102 verified the resident's tooth had been broken for almost a month now and the resident still had not seen a dentist. She stated the facility dentist usually comes back between visits to see emergency cases and to fit dentures, however she had not heard when he was going to return. She stated he usually visits every 60-90 days. The resident was on the list be seen next visit. She reported she would talk with nursing staff to see if the resident needed to be seen sooner since she was having questionable pain prior. Observation on 08/14/19 from 5:18 P.M. to 5:33 P.M., of Resident #43 revealed the resident would not open her mouth to visualize teeth. When asked she would smile but would not open her mouth or lips. The resident was observed eating dinner without difficultly. Review of the antibiotic stewardship policy dated 11/2017 revealed antibiotics would be prescribed and administered to residents under the guidance of the facility antibiotic stewardship program. Orientation, training and education of staff would emphasize the importance of antibiotics stewardship and would include how inappropriate use of antibiotics affect individual residents and the overall community. Appropriate indication for use of antibiotic include: McGeer's criteria met for clinical definition of active infection or suspected sepsis, pathogen susceptibility, based on culture and sensitivity, to antimicrobial. When antibiotics were prescribed over the phone, the primary care practitioner would assess the resident within 72 hours of the telephone ordered. The DON and infection preventionist, administrative and management personnel with clinical oversight responsibilities would receive initial orientation and ongoing training on the facility's antibiotic stewardship program and 365342 Page 13 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the rational for judicious use of antibiotics. The DON would monitor individual resident antibiotic regimens including reviewing clinical documentation supporting antibiotic orders and compliance with start/stop dates and/or days of therapy. The consultant pharmacist would identify, and flag orders for antibiotics that were not consistent with the antibiotic stewardship practice. The pharmacist would review the microbiology culture data (antibiogram) and share with the providers to help guide antibiotic selection. The pharmacist would participate in the meeting on a regular basis. Interview on 08/15/19 from 8:14 A.M. to 11:14 A.M, with the DON revealed the new policy for antibiotic stewardship was just reviewed in June 2019 and staff had not been educated on the new policy as of this time. The DON reported the only revision to the new policy was they added McGeer to the verbiage. The DON confirmed prior to that the staff were only educated on stop dates for antibiotics not the entire criteria. The DON reported she could not assess or review the labs antibiograms. The pharmacist was not reviewing them either per her knowledge. The DON verified the physician did not see Resident #43 within 72 hours of ordering antibiotics via phone per the policy. 365342 Page 14 of 15 365342 08/15/2019 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 and interview the facility failed to ensure Resident #32's room was maintained in a manner that was free from pests. This affected one resident (#32) of three residents reviewed for physical environment. Residents Affected - Few Findings include: Record review revealed Resident #32 was initially admitted on [DATE] and readmitted on [DATE] with a diagnosis including Alzheimer's Disease. Review of Resident #32's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/08/19 revealed the resident required supervision with bed mobility, transfers, and toileting, and his cognition was severely impaired. Observation on 08/12/19 at 12:02 P.M. of Resident #32's room revealed Resident #32 was sitting in his recliner with three flies flying around and landing on the resident. Observation on 08/14/19 at 2:34 P.M. with the Licensed Practical Nurse (LPN) verified there were three flies flying around and landing on Resident #32's recliner. Interview on 08/15/19 at 9:39 A.M. with Resident #32's family member revealed there were flies in the resident's room when they visit. 365342 Page 15 of 15