Health inspection·August 11, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy, and resident and staff interview, the facility failed to conduct quarterly care conference meetings. This affected one (Resident #5) of two residents reviewed for participation in care planning. The facility census was 77. Findings include: Review of the medical record for Resident #5 revealed an admission date of 11/05/20. Diagnosis included congested heart failure (CHF), thrombocytopenia, atrial fibrillation, cerebral vascular accident (CVA), candidiasis of skin and nail, major depressive disorder, chronic obstructive respiratory disease (COPD), and prediabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. The resident required extensive two person assistance for bed mobility, and total two person assistance for transfers. Review of the progress notes revealed the most recent care conference occurred on 10/28/21 at 2:32 P.M. Interview on 08/08/22 at 4:19 P.M. with Resident #5 stated he couldn't remember the last time he had participated in a care conference. Interview with the Director of Nursing (DON) on 08/11/22 at 8:26 A.M. confirmed the last care conference held for Resident #5 was on 10/28/21. The DON stated the facility did not have a social worker and they had hired a social worker scheduled to start work on 08/15/22. Review of the facility's policy titled Social Services Guidelines, dated 08/2021, revealed the interdisciplinary care conference is the culmination of the care planning process and is held in conjunction with Minimum Data Set (MDS) activity. Prior to the care conference, the patient is assessed through the MDS assessment process, and based on the findings for each care area, care plans are written and, or revised together with the patient, patient representative and family. The care conference is then scheduled to be held within seven days of the close of the MDS. The purpose of a care conference is for the interdisciplinary team to review their current findings and their focus moving forward. Page 1 of 4 365374 365374 08/11/2022 Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432

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. Based on medical record review and staff interview, the facility failed to have the physician review the pharmacy recommendation to conduct a gradual dose reduction recommendation of psychotropic medications. This affected one (Resident #11) of five residents reviewed for unnecessary medications. The facility census was 77. Findings include: Review of the medical record for Resident #11 revealed an admission date of 11/09/21. Diagnoses included end stage renal disease, schizoaffective disorder, and depression. Review of the monthly medication reviews dated 05/17/22 revealed the pharmacist documented in Resident #11's medical record that an irregularity existed, and a recommendation was made. The pharmacist recommended for the physician to conduct a gradual dose reduction (GDR) for bupropion ER 150 milligrams (depression), lamotrigine 150 milligrams (schizoaffective disorder), and hydroxyzine 50 milligrams (anxiety). Review of Resident #11's medication administration record (MAR) for May 2022, June 2022, and July 2022 revealed no GDR had occurred for bupropion ER 150 milligrams, lamotrigine 150 milligrams, and hydroxyzine 50 milligrams. Review of Resident #11's progress notes and physician orders for May 2022, June 2022, and July 2022 revealed no GDR for bupropion ER 150 milligrams, lamotrigine 150 milligrams, and hydroxyzine 50 milligrams had occurred. Further review of the progress notes revealed no documentation from the physician that a GDR of the medications was contraindicated. Interview on 08/11/22 at 8:30 A.M. with the Director of Nursing (DON) confirmed there was no copy of the pharmacy review for Resident #11 dated 05/17/22 and could not provide documentation from the physician indicating the GDR recommendation was contraindicated and that a GDR had not been conducted. 365374 Page 2 of 4 365374 08/11/2022 Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy, and staff interview, the facility failed ensure the residents were offered an influenza vaccine upon admission or yearly during the influenza season. This affected two (Residents #11 and #54) of five residents reviewed for updated influenza vaccines. The facility census was 77. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #11 revealed an admission date of 11/09/21 with diagnoses including end stage renal disease, schizoaffective disorder, and depression. Further review of the medical record for Resident #11 from November 2021 through August 2022 revealed no documentation that an influenza vaccine had been offered upon admission or after. The medical record also was without documentation that the influenza vaccine had been refused or was contraindicated. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11's influenza vaccine was not administered and the reason for it not given was coded as nine, which indicated there was no reason for it to not be administered. Review of Resident #11's physician orders revealed the resident was able to have the influenza vaccine yearly. Review of Resident #11's physician progress notes revealed no documentation that an influenza vaccine was contraindicated. Interview with the MDS Coordinator #208 on 08/11/22 at 2:33 P.M. revealed he had coded the MDS as a nine because there was no evidence Resident #11 was given an influenza vaccine. 2. Review of the medical record for Resident #54 revealed an admission date of 03/09/20 with diagnoses including diabetes mellitus, schizophrenia, and chronic kidney disease stage three. Further review of the medical record for Resident #54 from September 2021 through August 2022 revealed no documentation that an influenza vaccine had been given in October 2021. The medical record also was without documentation that the influenza vaccine had been refused or was contraindicated. Review of the quarterly MDS assessment dated [DATE] revealed Resident #54's influenza vaccine was not given and the reason for it not given was coded as nine, which indicated there was no reason for it to not be administered. Review of the immunization log for Resident #54 revealed the last influenza vaccine had been administered on 10/22/20. Review of Resident #11's physician progress notes for revealed no documentation that an influenza vaccine was contraindicated. Interview with the MDS Coordinator #208 on 08/11/22 at 2:33 P.M., revealed he had coded the MDS as 365374 Page 3 of 4 365374 08/11/2022 Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a nine because there was no evidence Resident #54 was given an influenza vaccine. The MDS Coordinator #208 further stated he remembered when the influenza vaccine was offered in October of 2021, Resident #54 was feeling ill, so they did not give it to her. MDS Coordinator #208 stated there was no evidence in the record that anyone offered the influenza vaccine after her period of illness was over. Interview on 08/11/22 at 2:18 P.M. with the Director of Nursing (DON) confirmed there was no copy of the influenza consent for Resident #11 or Resident #54 and could not provide documentation from the physician indicating the influenza vaccine was refused or contraindicated. Review of the facility's policy titled Screening and Vaccinations, dated May 2022, revealed the resident is to be screened upon admission for current influenza vaccine status. If the resident is found to not have had a current influenza vaccine, they are to be offered education about influenza and provided a consent form to accept or decline the influenza vaccine. Influenza consent, education, and administration are to be documented in the resident record. 365374 Page 4 of 4