Health inspection·November 26, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure advanced directives listed in the medical record were accurate. This had the potential to affect two residents (#19 and #45) of three reviewed for advanced directives. The facility census was 54. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 08/29/19 with diagnoses including pulmonary fibrosis, depressive disorder, epilepsy, chronic kidney disease, and pneumonia. Review of Resident #19's physician order dated 08/29/19 revealed an order for the resident to be a Full Code. Review of Resident #19's Do Not Resuscitate (DNR) identification form dated 09/18/19, revealed the resident was identified as having Do No Resuscitate Comfort Care (DNRCC). The DNRCC form was signed by the physician. Review of Resident #19's Medication Administration Record (MAR) dated November 2019 listed the resident as a Full Code. Review of Resident #19's information profile of the electronic medical record identified the resident's code status as full code. Interview on 11/25/19 at 9:09 A.M. with Director of Nursing (DON) verified Resident #19 MAR listed the resident as a Full Code and the physician had signed an order for the resident to be a DNRCC on 09/18/19. 2. Review of the medical record for Resident #45 revealed an admission date of 03/02/16 with diagnoses including major depression, dementia with behavioral disturbance and hyperlipidemia. Review of the face sheet located in Point Click Care (PCC) revealed Resident #45 was a Full Code status. Review of the physician orders dated 11/21/19 code status changed to DNR. Page 1 of 4 365418 365418 11/26/2019 Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/25/19 at 11:07 A.M. with Licensed Practical Nurse (LPN) #200 verified Resident #45's Advance Directives were located in the medical record hard chart as a DNR and in the computer (PCC) the code status was a Full Code. Review of facility policy tilted Do Not Resuscitate Order dated April 2017, revealed a Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and the resident (or resident's legal surrogate) and placed in the front of the resident's medical record. 365418 Page 2 of 4 365418 11/26/2019 Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420

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, resident interview, staff interview, and review of facility policy, the facility failed to ensure all residents were given an opportunity to take part in the planning of his/her own care. This affected two residents (#22 and #39) of 25 residents reviewed. The facility census was 54. Findings include: 1. Medical record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease, diabetes mellitus and hypertension. Further review revealed no documented evidence the resident was invited to attend and/or attended a care planning conference. Interview on 11/24/19 at 10:16 A.M., with Resident #22 revealed she had no recollection of being invited to or attending a care planning conference since her admission on [DATE]. Interview on 11/25/19 at 1:25 P.M., with the Social Service Director (SSD) #220 revealed she was responsible for scheduling care planning conferences with residents and/or resident's representatives. SSD #220 revealed she was not currently offering admission care planning conferences to any new resident unless they were a short stay rehabilitation patient. SSD #220 verified, to date, no care planning conference has been conducted for Resident #22. 2. Medical record review revealed resident #39 admitted to the facility on [DATE] with diagnoses including hypertension, hypothyroidism and hyponatremia. Further review revealed a care planning conference was held for the resident on 10/20/19. No other documented evidence any other care planning conference was held for the resident. Interview on 11/24/19 at 10:00 A.M., with Resident #39 revealed he could not remember attending a care planning conference other than the one that was held on 10/20/19. Interview on 11/25/19 at 1:25 P.M., with SSD #220 verified Resident #39 was invited to a care planning meeting on 10/20/19 and verified this was the first care planning meeting held for Resident #39. Review of a facility policy titled, Resident Participation-Assessment/Care Plans, most recent revision date 12/2016, revealed the resident and/or resident representative had the right to participate in the development and implementation of his or her plan of care. The care planning process was to facilitate the inclusion of the resident and/or resident representative. 365418 Page 3 of 4 365418 11/26/2019 Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident's pulse oximetry levels were monitored as ordered by a physician. This affected one Resident (#19) of six reviewed who were ordered to monitor pulse oximetry levels. The facility census was 54. Residents Affected - Few Findings include: Review of Resident #19's medical record revealed an admission date of 08/29/19 with diagnoses including pulmonary fibrosis, chronic kidney disease, and pneumonia. Review of Resident #19's care plan dated 09/10/19 revealed the resident had been addressed as having altered respiratory status/difficulty breathing related to pulmonary fibrosis. Interventions included to monitor for increased respirations, decreased pulse oximetry, and increased heart rate. Review of Resident #19's physician order dated 11/16/19 revealed an order to wean off oxygen and keep pulse oximetry above 92%. Review of Resident #19's Treatment Administration Record (TAR) dated November 2019 revealed no evidence of any pulse oximetry levels documented. Interview on 11/25/19 at 9:34 A.M. with Licensed Practical Nurse (LPN) #215 verified Resident #19's pulse oximetry levels had not been documented as being monitored as ordered by the physician. Review of facility policy titled Pulse Oximetry (Assessing Oxygen Saturation) dated October 2010, revealed the pulse oximetry flow sheet should be placed in the resident's medical record. 365418 Page 4 of 4