Health inspection·August 8, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and facility policy review the facility failed to ensure all staff, including medical providers, treated two residents (Resitens #5, and #9) with dignity when entering their rooms and during care. This affected two of 14 residents reviewed for dignity. Findings include: 1. On 08/05/19 at 9:50 A.M. a physician (who was later identified as the Medical Director) was observed entering the room of Resident #5, which had the door closed, without knocking or announcing himself. Two state tested nursing assistants (STNA) were observed in the room providing personal care to the resident. The physician did not ask permission to enter upon opening the door. During an interview on 08/05/19 at 10:00 A.M., Resident #5 stated the physician never knocks on our door, he just walks in and further stated other staff in the building do knock before they come in. On 08/05/19 at 11:30 A.M. the Medical Director approached the surveyor and stated, I have never been instructed by the former director [administrator] at the facility about knocking on doors and that he had not been told by the present director. He also stated, I don't think the facility should be held accountable for what I didn't know. 2. Observation on 08/05/19 at 10:12 A.M. a male, later identified by the Administrator as the Medical Director, walked in Resident #9's room while the resident was speaking with the surveyor. The gentleman walked in without knocking or asking permission to enter, interrupting the surveyor interview with Resident #9. The surveyor exited the room at that time. A brief interview with the Administrator, at 10:30 A.M. on 08/05/19, revealed the gentleman was the Medical Director and one of three attending physicians who saw residents in the facility. On 08/06/19 at 9:35 A.M. an interview was conducted with Resident #9, about the previous day, when the Medical Director entered her room without knocking or asking permission, while she was meeting with the surveyor. She stated, He's the only one who doesn't knock; the housekeepers, aides, nurses and all knock before entering. He should knock or ask first. This is my home. During an interview with the Administrator, on 08/07/19 at 12:45 P.M., she revealed she would expect the Medical Director to knock on doors and ask permission prior to entering a room. She stated she educated him on 08/05/19 when she was asked, by the surveyor, who he was and was told he was walking into rooms without knocking. Page 1 of 13 365354 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Quality of Life-Dignity, last revised in August 2009 indicated Residents' private space and property shall be respected at all times. Staff will knock and request permission before entering residents' rooms. Residents Affected - Few 365354 Page 2 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility policy review the facility failed to ensure physical examinations and discussion of private health information for two residents (Residents #7 and #9) were conducted privately. This affected two of 14 residents reviewed for privacy. Residents Affected - Few Findings include: 1. Observation revealed, on 08/05/19 at 10:12 A.M. a male, who was later identified as the Medical Director, walked in Resident #9's room while the resident was speaking with the surveyor. The gentleman walked in without knocking or asking permission to enter, interrupting the surveyor interview with Resident #9. The gentleman then began to discuss Resident #9's care in front of the surveyor and leaned down and placed a stethoscope on the resident's chest, to listen to her heart and lungs. The surveyor exited the room at that time. Brief interview with the Administrator at 10:30 A.M. on 08/05/19 revealed the gentleman was the Medical Director and one of three attending physicians seeing residents in the facility. On 08/06/19 at 9:35 A.M. an interview with Resident #9, about the previous day when the Medical Director entered her room without knocking or asking permission while she was meeting with the surveyor, she stated, He should have asked to examine me when he walked in. He might have asked private things I wouldn't want to share with you. 2. On 08/05/19 at 10:45 A.M. the physician was observed in the main dining room during an activity where Resident #7 was involved. The physician was observed to approach her, and without speaking to her or explaining what he was going to do, proceeded to complete an assessment, by placing his stethoscope on the front and back of her chest and physically touched her ankles with his hands. When he was finished, he walked away from her, again without speaking to her. During an interview on 08/06/19 at 1:20 P.M. with Resident #7, regarding the assessment by the physician on 08/05/19, she stated, he knows he isn't supposed to do that in public. She also confirmed that the physician did not speak to her during the brief assessment or explain what he was going to do. During an interview with the Administrator, on 08/07/19 at 12:45 P.M., she revealed she would expect the Medical Director to respect residents' privacy. Review of the facility policy titled, Quality of Life-Dignity, last revised in August 2009 indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 365354 Page 3 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure urinary output was tracked as ordered for one resident (Resident #37) with an indwelling urinary catheter. This affected one of two residents reviewed for urinary catheters. The facility census was 66. Findings include: Review of Resident #37's admission Minimum Data Set (MDS) Assessment, (an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning) with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 01/10/19, revealed the facility admitted the resident on 01/03/19 with diagnoses of spina bifida, generalized muscle weakness, neuro muscular dysfunction of the bladder, essential (primary) hypertension, and three pressure ulcers. In addition, the MDS Assessment indicated under Section V Care Area Assessment section, the resident was admitted with urinary incontinence and an indwelling catheter/urinary ostomy. Review of the Quarterly MDS Assessment, with an ARD date of 07/03/19, revealed the resident was again coded as having urinary incontinence with a urinary catheter/ostomy. Review of the resident's Comprehensive Care Plan, revealed a focus area, originally initiated on 01/03/19, for bladder elimination complications related to the resident's cystostomy and for ensuring no signs or symptoms of infection until the next review. One intervention listed was, Observe output and record. Notify the MD [Medical Doctor]/NP [Nurse Practitioner] of any abnormalities. Observation, on 08/06/19 at 9:36 AM, revealed Resident t#37 was in bed, covered, with his eyes closed. A catheter drainage tube was visible and connected to a bedside drainage bag. Review of a hospital report, that was untitled with only the local hospital name in the heading, in Resident #37's clinical record, revealed the resident was admitted to the hospital on [DATE] with fever and abdominal pain, and was diagnosed with an infection of a wound/ulcer. The resident was discharged back to the facility on [DATE] with an oral antibiotic, Amoxicillin, prescribed until 06/08/19. Prior to the hospitalization, the resident had been taking Nitrofurantoin for the prevention of urinary tract infections (UTIs). Review of an order dated 05/22/19, under the Clinical Physician's Orders tab in the electronic medical record (EMR), for Resident #37, read, OUTPUT three (3) times a day. The order did not include a stop date for measuring the urinary output. Review of the Daily Skilled Nurses Notes and Progress Notes from 05/22/19 to 08/07/19, revealed nurses had not recorded any information about Resident #37's urinary output for the days where documentation was missing on the May, June, July, and August 2019 TARs. Interview, on 08/06/19 at 9:48 A.M. with State Tested Nursing Assistant (STNA) #1, revealed if there was an order for measuring Resident #37's urinary output, there would be an area in the electronic charting system the STNAs could access. However, when STNA #1 opened the electronic charting 365354 Page 4 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few program, via a wall mounted system in the hallway, she did not find a tabbed area/icon for recording anything about Resident #37's urinary output. Observation, on 08/06/19 at 3:10 P.M., of perineal (peri) care for Resident #37, revealed STNA #1 emptied urine from the cystostomy collection bag into a triangular graduate container. The STNA took the urine to the resident's bathroom and poured it into the toilet. When the STNA left Resident #37's room, she said her shift was over and left for the day. STNA #1 was not observed recording or reporting any information to the nurse about the resident's output. Review on 08/07/19 of the August Treatment Administration Record (TAR), revealed Resident #37's urinary output was not recorded in the 08/06/19, 2:00 P.M. space provided on the TAR. Interview, on 08/07/19 at 11:30 A.M. with STNA #3, revealed on occasion, Resident #37 might empty the urine from his cystostomy bag, but at the change of shifts, around 10:30 P.M., and at 6:30 A.M., for example, the STNA on duty should empty the urine collection bag, and report the output to the nurse on duty. STNA #3 said she thought the nurses documented the information about Resident #37's output. Interview, on 08/07/19 3:00 P.M. with Registered Nurse (RN) #1, revealed the STNAs were to measure Resident #37's urine output three times daily, and report the information to the nurse on duty. The RN said the nurse should record the information on the TAR where the order was listed. RN #1 said the staff should monitor and record the resident's urinary output because the resident had a diagnosis of neuromuscular dysfunction of the bladder, a cystostomy, and a history of chronic UTIs. RN #1 said monitoring the resident's urinary output for its color, consistency, and amount would help the nurses know if the resident was having trouble voiding or if he was having symptoms of a UTI. RN #1 said the physician should be notified of any abnormalities. Review of the TAR for Resident #37 revealed an order, dated 05/22/19, was transcribed onto the TAR and indicated the resident's urinary output should be recorded at 6:00 A.M., 2:00 P.M., and 10:00 P.M., daily. Review of the May 2019 TAR revealed beginning on May 22nd, the nursing staff recorded their initials and/or a urine amount only 14 times out of 29 required entries. The dates with missing documentation were 05/24/19, 05/25/19, 05/26/19, 05/27/19, 05/28/19, 05/30/19, and 05/31/19. Review of the June 2019 TAR revealed nurses did not record their initials and/or a urinary output amount a total of seven times out of 90 required entries. The dates with missing documentation were 06/09/19, 06/19/19, 06/26/19, 06/27/19, 06/29/19, and 06/30/19. Review of the July 2019 TAR revealed nurses did not record their initials or a urinary output amount a total of four out of 93 required entries. The dates with missing documentation were 07/21/19, 07/22/19, 07/23/19, and 07/31/19. Review of the August 2019 TAR up to 08/07/19, revealed nurses did not record their initials and/or the output a total of two out of a required 21 entries. Continued interview with RN #1 on 08/07/19 at 3:00 P.M. revealed upon his review of the documentation on the May-August TARs for Resident #37, he said there was missing documentation about the resident's urinary output. The RN verified if the staff was not recording the resident's output three times daily, then the care was not being provided per the physician's order, as related to Resident #37's cystostomy status. 365354 Page 5 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview, on 08/07/19 at 3:24 P.M. with the Director of Nursing (DON) confirmed according to the order, Resident #37's output should have been monitored three times daily, and that the order was still active. The STNA should empty the cystostomy bag and report the amount of urine and any other unusual characteristics of the resident's urine to the nurse. The nurse should document on the TAR or in the Daily Skilled Nurses' Notes. The DON verified if Resident #37's urinary output was not recorded on the TAR or in the nurses' notes, then the physician's order was not followed. The DON said the resident had not been out of the facility for any extended periods of time since his hospitalization of 05/18/19-05/20/19. Review of the facility policy, titled Medication Orders, Revision Date, November 2014, revealed treatment orders should specify the treatment, the frequency, and duration of the treatment. 365354 Page 6 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure that residents were free from medications used without adequate indication, for one resident (Resident #6). This affected one of of 17 sampled residents. The facility census was 66. Residents Affected - Few Findings include: According to the facility Face Sheet (undated), Resident #6 was admitted to the facility on [DATE]. The face sheet revealed diagnoses of unspecified dementia without behavioral disturbance, overactive bladder, and generalized muscle weakness. No diagnosis of a history of urinary tract infections (UTI) was found in the clinical record. No documentation was found that Resident #6 had a urology consult or was seen by a urologist. According to the quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 05/10/19, revealed Resident #6, in Section C, which assessed the resident's cognitive status, had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated that Resident #6 was severely cognitively impaired. Section G, which scored functional status, revealed Resident #6 required extensive assistance for personal hygiene. Section H, which scored bladder and bowel function, indicated Resident #6 was always incontinent of urine. According to Resident #6's Progress Notes, she was diagnosed and treated for a UTI seven times from 07/11/18 to 05/17/19. No clear documentation could be found in Resident #6's Progress Notes that indicated the rationale for obtaining the urine specimens for urinalysis (UA) the rationale for treatment with no clinical signs and symptoms of a UTI, nor what Resident #6's normal baseline for confusion was. During an interview with Licensed Practical Nurse (LPN) #1, on 08/05/19 at 9:15 A.M., she stated the resident rarely got out of bed, was dependent on staff for all care, and at times her husband, who she shared a room with, would not allow care to be completed for Resident #6. During an interview with Resident #6, on 08/05/19 at 10:00 A.M., she was pleasantly confused and did not recognize her spouse, who was in the room. During the interview Resident #6 voiced confusion at hearing from her husband that they were married. Resident #6 was not distressed during the interview. During an interview with the Director of Nursing (DON) on 08/06/19 at 12:00 P.M., the DON stated that Resident #6 did not present with the usual signs and symptoms for a UTI, but only showed increased confusion. The DON was unable to specify what the increased confusion was, apart from her normal baseline confusion, and was unable to state what Resident #6's normal baseline confusion was. During an interview on 08/08/19 at 10:30 A.M., with the DON, she stated she was aware that the resident had been treated for multiple UTI's over the past year. She was not aware of the lack of documentation by the nursing staff to indicate the rationale for obtaining a UA or initiating an antibiotic. She also stated they follow McGeer's criteria (specific criteria developed by infection preventionist professionals to determine the presence of a true infection) for antibiotic use and that the resident was known to only exhibit increased confusion as an indicator of a potential UTI. (The use of criteria to identify true infections was to prevent the overuse of antibiotics and potential 365354 Page 7 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0757 subsequent adverse effects.) Level of Harm - Minimal harm or potential for actual harm During the same interview on 08/08/19 at 10:30 A.M. the DON was informed of the interview with Resident #6 on 08/05/19 at 10:00 A.M. and how she didn't recognize her husband until her husband mentioned his name. The DON was asked, based on previous history with Resident #6, would this confusion require a UA to be completed? The DON stated, No. Residents Affected - Few On 07/06/18 at 3:16 P.M. the Progress Notes revealed increased confusion at this time. Is not recognizing her husband, who is her roommate, stating that is not him, that's just some criminal that wants my money. Physician faxed to obtain order for UA with C&S [urinalysis with culture and sensitivity]. On 07/06/18 at 6:16 P.M. the Progress Notes revealed the resident was currently able to identify husband. Resident #6 was noted to have a diagnosis of dementia with history of altered mental status. On 07/11/18 at 11:48 P.M. the Progress Notes revealed the UA and C&S results were reported to the physician and new orders for an antibiotic, Nitrofurantoin (Macrobid) 100 mg twice a day for 5 days was ordered. No documentation could be found from 07/06/18 to 07/11/18 which indicated that Resident #6 was still showing signs of increased confusion, or other signs and symptoms of a UTI when the antibiotic was started on 07/12/18. Resident #6 completed the full course of antibiotic therapy. According to the Progress Notes dated 08/28/18, an order was received to collect a urine specimen for UA and C&S. No documentation was found which explained the rationale for the UA, or any documented clinical signs and symptoms for a UTI. On 09/02/18 at 4:02 P.M. the Progress Notes indicated results of a urine C&S were reported to the physician, new orders for Augmentin (antibiotic) three times a day for five days were received. There was documentation found of signs and symptoms of a UTI. According to the Progress Notes dated 10/13/18, an order was received to collect a urine specimen for UA and C&S. Resident #6's Progress Notes did not include the rationale for the UA, such as, clinical signs and symptoms for a UTI. On 10/17/18 at 2:04 P.M. the Progress Notes indicated the physician made aware of UA and C&S results, new orders for Macrobid 100 mg two times a day for UTI for seven days were obtained. The progress note did not include clinical signs and symptoms of a UTI. Resident #6 completed the full course of antibiotic therapy. According to the Progress Notes dated 12/06/18, an order was received to collect a urine specimen for UA and C&S. No documentation was found which explained the rationale for the UA, or any clinical signs and symptoms for UTI. On 12/07/18 at 7:18 P.M. the Progress Notes indicated preliminary UA results in, start Macrobid 100 mg by mouth twice a day until C&S comes in The final UA and C&S was completed on 12/10/18. The physician ordered to continue the Macrobid to equal a 10-day course, which would finish on 12/17/18. Resident #6 completed the full course of antibiotic therapy. On 03/18/19 at 9:31 P.M. the Progress Notes indicated State Tested Nursing Assistant (STNA) made this nurse aware of lack of voiding this shift and the resident's odd behaviors including but not 365354 Page 8 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few limited to yelling out, delusions, and refusal of care. This nurse obtained an order to straight cath the resident to relieve retention and obtain urine for UA. No documentation could be found that described the extent of the odd behaviors or delusions nor was there any documentation on the amount of urine obtained to relieve retention. The physician ordered Macrobid 100 mg by mouth twice a day for 10 days on 03/21/19, for Resident #6's UTI. The record lacked mention of clinical signs and symptoms in 03/18/19 progress note. She completed the full course of antibiotic therapy. According to the Progress Notes dated 04/15/19, an order was received to collect a urine specimen for UA and C&S. No documentation was found which explained the rationale for the UA or any documented clinical signs and symptoms for a UTI. The Nurse Practitioner (NP) ordered an antibiotic, Bactrim DS one tablet by mouth twice a day for 10 days on 04/15/19. She completed the full course of antibiotic therapy. On 05/16/19 at 12:02 P.M. the Progress Notes indicated the NP was made aware of preliminary UA results. Increased behaviors were noted; however the resident had diagnosis of dementia. No documentation could be found in the clinical record that described the increased behaviors or on what date the urine specimen was obtained. Despite the lack of clinical signs and symptoms of a UTI, on 05/18/19 at 12:55 A.M., the Progress Notes indicated UA results were reported to the NP who gave new orders for another antibiotic, Cipro 500 mg by mouth daily for seven days On 05/20/19 at 9:43 A.M. the Progress Notes revealed final UA results were reported to the NP that the infection was resistant to Cipro. New orders were obtained to discontinue Cipro and start another antibiotic, one gram of Ertapenem intramuscular (IM) daily for 10 days. On 06/27/19 at 12:35 P.M. the Progress Notes indicated the resident presented with increased confusion, speaking of the dog in her room that someone needs to be taking care of. The NP was notified and a new order to start Macrobid 100 mg daily by mouth for lifetime prophylactically secondary to recurrent UTIs. Also, Hiprex [an anti-infective] one gram by mouth twice daily. No documentation could be found in Resident #6's clinical record that indicated the rational for ordering the antibiotic with no stop date, nor the clinical signs and symptoms of a UTI, as recommended by the facility's Antibiotic Stewardship policy and the McGeer's criteria followed by the facility. During an interview on 08/08/19 at 10:30 A.M., with the DON, she stated the NP had seen, and documented on, the resident on 7/10/19 and stated the reasoning for placing Resident #6 on the Macrobid prophylactically for lifetime, along with the Hiprex. However, no documentation could be found in the resident chart from the NP and the DON was unable to locate the documentation before exit on 08/08/19. According to the facility Antibiotic Stewardship policy, dated October 2017, it stated under section 4, bullet v - Microbiologic specimen submission guidelines - The following guidelines should be considered before submission of a clinical specimen for microbiologic testing: utilize McGeer's criteria. Section 4 of the policy further defined McGeer's criteria for UTI without a catheter as Acute dysuria, fever or leukocytosis [an inflammatory response] and at least one of the following: acute flank pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency and new or marked increase in frequency. In the absence of fever or leukocytosis, then two or more of the following subcriteria: gross hematuria, new or marked increase in incontinence, new or marked increase in urgency and new or marked increase in frequency and At least one of the following: At 365354 Page 9 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0757 Level of Harm - Minimal harm or potential for actual harm least 105 colony forming unit (cfu)/millimeters (ml) of no more than two species of microorganisms in a voided urine sample or at least 102 cfu/ml of any number of organisms is a specimen collected by straight catheterization Residents Affected - Few 365354 Page 10 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to store food in the dry storage room and in the walk-in freezer in a sanitary manner. The facility also failed to store pans and pitchers in a sanitary manner. This had the potential to affect all 66 residents who currently resided in the facility and ate food prepared in the kitchen. Finding include: On 08/05/19 the following observations were made in the facility kitchen: At 9:10 A.M., the [NAME] Beach stainless steel blender was observed on a food preparation counter across from the steam table. Upon removal of the lid, the blender pitcher had water in the pitcher. The dietary manager (DM) stated the blender had been used the evening before to puree desserts. When asked if the blender pitcher was supposed to be stored wet, the DM stated, No. At 9:13 A.M., in the dry storage room, a bag of bleached flour was observed to be open and exposed. The DM stated, It should be sealed. Also, a bag of crispy onions was open and exposed. When shown the bag of crispy onions, the DM stated the bag should be thrown away. At 9:17 A.M., on the pan rack, a total of six stainless steel pans of various sizes were observed to have water dripping from them when lifted from the stacks. When asked if the pans were to be stored/stacked wet, the DM stated, No. They are supposed to be dry. At 9:22 A.M., in the walk-in freezer, a bag of pizza crusts, a bag of [NAME] filets, and a bag of beef patties were observed to be opened and exposed. When asked if the bags of food in the freezer were supposed to be opened and exposed, the DM stated, No. At 9:28 A.M., five plastic pitchers with lids securely in place were observed to have water in them. When asked if the pitchers were supposed to be stored wet, the DM stated, No. The facility's undated Dry Storage and Supplies policy and procedure, documented: Opened food shall be stored in resealed containers/food bags that are labeled/dated. The facility's undated Dish Machine Use policy and procedure, documented: Dishes shall be air-dried and never stored wet. 365354 Page 11 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

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 observation, interview, record review, and review of the facility's policy, the facility failed to maintain accurate and complete medical records for one (Resident #9) regarding diagnoses that were actually associated with another resident in the facility. This affected one of 19 sampled resident whose records were reviewed. Findings include: Review of Resident #9's Face Sheet, from the Demographics Tab in the electronic medical record (EMR), revealed she was admitted on [DATE]. Her Diagnosis Report, from the Diagnoses tab of the EMR revealed admitting diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), major depressive disorder (recurrent), and sleep apnea. Diagnoses of schizophrenia and cerebral palsy were added to the diagnosis list on 03/30/18. On 01/22/18 her attending physician, who was also the Medical Director, wrote two Physician Progress Notes, in the Progress Note tab of the EMR. The notes timed at 2305 (11:05 P.M.) documented Resident #9 had a Past Medical History including 1) Type 2 diabetes, 2) heart failure, 3) COPD, 4) obesity, 5) obstructive sleep apnea, 6) anxiety disorder, 7) major depression, 8) hyperlipidemia and 9) chronic pain. In the second note, with the same date, timed at 2316 (11:16 P.M.) the Medical Director documented, I've seen [another resident's name] is [sic] Past Medical History 1) schizoaffective disorder, 2) cerebral palsy, . 5) schizophrenia. The Medical Director subsequently documented in the Progress Note tab on 02/23/18, 03/12/18, 04/09/18, 05/14/18, 06/08/18, 07/10/18, and 08/13/18 the resident had a Past Medical History of schizoaffective disorder, cerebral palsy, and schizophrenia. None of which were mentioned in Resident #9's Diagnosis Report. Additional notes on 09/10/18, 10/05/18, 11/05/18, 12/04/18, 01/27/19, 03/05/19, 04/01/19, 05/13/19, 06/03/19 and 08/05/19 revealed the Medical Director continued to document a past history of schizoaffective disorder and cerebral palsy. On 08/07/19 at 11:00 A.M., during an interview, Resident #9 stated the diagnoses of schizo-affective disorder, cerebral palsy, and schizophrenia were not hers. During an interview with the Director of Nursing (DON) and Regional Registered Nurse (RN) Quality Assurance (QA) Consultant, at 11:24 A.M. on 08/07/19 revealed the DON was not aware there were two notes written 11 minutes apart; one included diagnoses that belong to Resident #9 and the other included the name and diagnoses of another resident. The DON confirmed the resident's name, that appeared in Resident #9's 01/22/18 Progress Note, timed at 11:16 P.M., was a current resident whose diagnoses included schizoaffective, schizophrenia and cerebral palsy. She stated she thought the Medical Director probably documented on the wrong resident in Resident #9's chart. The DON stated she would expect his notes to be accurate in each resident's record. An interview was conducted with the Medical Director on 08/07/19 at 2:14 P.M. about the addition of 365354 Page 12 of 13 365354 08/08/2019 Longmeadow Care Center 565 Bryn Mawr Ravenna, OH 44266

F 0842 Level of Harm - Minimal harm or potential for actual harm the diagnoses of schizophrenia, schizoaffective and cerebral palsy for Resident #9. He verified his notes from 01/22/18, where he documented on the other resident in Resident #9's chart, and stated, Shouldn't the facility have caught it? When asked if he looked at the psychiatry notes he said, No because they don't come. The Medical Director further shared, I copy and paste the diagnoses each visit because it's easier than reviewing their medical diagnoses each visit. Thanks for pointing that out to me. Residents Affected - Few Review of the facility's policy, titled Charting and Documentation, revised July 2017, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 365354 Page 13 of 13