Health inspection·June 30, 2022

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) assessments were accurate. This affected four residents (#40, #6, #37, and #4) of four reviewed for accuracy of MDS assessments. The facility census was 62. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 02/10/22 with diagnoses including dementia with behavioral disturbance, anxiety disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment indicated a wander/elopement alarm was not used and wandering was not exhibited. Review of the progress notes 05/13/22 at 2:04 P.M., 05/16/22 at 3:58 P.M., 05/17/22 at 3:40 P.M., 05/17/22 at 4:09 P.M., 05/18/22 at 4:13 P.M., and 05/18/22 at 9:42 P.M. revealed the resident exhibited wandering and exit seeking behaviors. Review of the physician's orders for June 2022 identified orders for a Wander Guard device (ordered 02/10/22). On 06/27/22 at 9:35 A.M., observation of Resident #40 revealed she was walking up and down the memory care hallway and attempted to exit the unit. The door alarm sounded and the resident did not open the door. On 06/27/22 at 9:47 A.M., interview with Licensed Practical Nurse (LPN) #359 revealed Resident #40 exhibited wandering and exit seeking behaviors. LPN #359 stated Resident #40 had attempted to exit the unit and the door alarms sounded because she was wearing a Wander Guard. On 06/29/22 at 10:02 A.M., observation of Resident #40 revealed she walked out the doors of the memory care unit and the door alarms sounded. On 06/29/22 at 10:06 A.M., observation of Resident #40 revealed she attempted to open the exterior door of the memory care unit and was unsuccessful. On 06/29/22 at 10:09 A.M., interview with LPN #392 confirmed Resident #40 exhibited wandering and exit seeking behaviors. LPN #392 stated Resident #40 had a Wander Guard and the door alarms would sound if she attempted to exit the unit. Page 1 of 5 365429 365429 06/30/2022 Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832

F 0641 Level of Harm - Minimal harm or potential for actual harm On 06/29/22 at 10:22 A.M., observation of Resident #40 revealed she attempted to open the exterior door of the memory care unit and was unsuccessful. On 06/29/22 at 10:27 A.M., interview with Registered Nurse (RN) #313 revealed Resident #40 occasionally exited the memory care unit and the door alarms would sound. Residents Affected - Some On 06/29/22 at 3:41 P.M., interview with RN #354 verified Resident #40 had a Wander Guard and the MDS assessment dated [DATE] indicated she did not use a wander/elopement alarm. RN #354 also verified Resident #40 exhibited wandering behaviors and the MDS assessment dated [DATE] indicated no wandering behaviors had occurred. 2. Review of the medical record for Resident #6 revealed an admission date of 06/09/22 with diagnoses including schizophrenia, anxiety disorder, schizoaffective disorder, Alzheimer's disease, delusional disorders, and major depressive disorder. Review of the physician's orders for June 2022 identified orders for Tramadol HCl 50 milligrams (mg) as needed for pain. Review of the admission MDS assessment dated [DATE] indicated Resident #6 received an opioid for seven days during the seven day lookback period. Review of the medication administration record (MAR) for 06/10/22 through 06/16/22 revealed Resident #6 received Tramadol HCl five out of seven days during the seven day lookback period for the MDS assessment dated [DATE]. On 06/30/22 at 9:29 A.M., interview with Registered Nurse (RN) #387 verified the MDS assessment dated [DATE] indicated Resident #6 had received an opioid for seven days during the seven day lookback period and Resident #6 had only received Tramadol five out of seven days. 3. Review of the medical record for Resident #37 revealed an admission date of 02/24/22 with diagnoses including major depressive disorder, paroxysmal atrial fibrillation, heart failure, and atherosclerotic heart disease of native coronary artery. Review of the physician's orders for May 2022 identified orders for rivaroxaban (anticoagulant) tablet 20 milligram (mg) daily. Review of the quarterly MDS assessment dated [DATE] indicated Resident #37 received an anticoagulant for seven days during the seven day lookback period. Review of the medication administration record (MAR) for 05/07/22 through 05/13/22 revealed Resident #37 received rivaroxaban for six out of seven days during the seven day lookback period for the MDS assessment dated [DATE]. On 06/29/22 at 3:23 P.M., interview with Registered Nurse (RN) #354 verified the MDS assessment dated [DATE] indicated Resident #37 had received an anticoagulant for seven days during the seven day lookback period and had only received rivaroxaban for six out of seven days. 4. Review of the medical record for Resident #4 revealed an admission date of 03/19/22 with diagnoses including dementia with behavioral disturbance, anxiety disorder, and depression. 365429 Page 2 of 5 365429 06/30/2022 Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician's orders for June 2022 identified orders for a Wander Guard device (ordered 05/09/22). Review of the quarterly MDS assessment dated [DATE] indicated no wander/elopement alarm was used. On 06/30/22 at 9:29 A.M., interview with Registered Nurse (RN) #387 verified Resident #4 had a physician's order for a Wander Guard device and the MDS assessment dated [DATE] indicated no wander/elopement alarm was used. RN #387 stated she did not realize Resident #4 had a Wander guard and that is why it was not indicated on the MDS assessment. 365429 Page 3 of 5 365429 06/30/2022 Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832

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 review of the medical record, observation and staff interview the facility failed to ensure Resident #18 and #27 were properly supervised in the dining room during meal time. This affected two residents (Resident #18 and #27) of seven observed for dining service. Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included myocardial infarction, respiratory failure, congestive heart failure, diabetes, urinary tract infection, asthma, COVID-19, hypotensive, chronic obstructive pulmonary disease, cataract, hypoxemia, sleep apnea, dysphagia (difficulty swallowing), dementia, macular degeneration, and anxiety disorder. Review of the Medical Nutrition Re-assessment dated [DATE] revealed Resident #27 ate in the dining room for supervision and assistance. She was on a mechanical soft diet. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition and required supervision with eating. Further review revealed she was on a mechanically altered diet. Review of the June 2022 physician orders revealed Resident #27 was ordered a consistent carbohydrate, no added sugar, mechanical soft texture with nectar thick consistency diet and the speech therapist recommended she eat in the dining room for assistance. Review of the Point Click Care task from 06/01/22 to 06/30/22 revealed Resident #27 required extensive assistance with eating for four meals, limited assistance for one meal and supervision for 12 meals. Observation on 06/27/22 at 5:55 P.M. revealed Resident #27 and #18 were in the dining room eating supper with no supervision. Interview on 06/27/22 at 6:01 P.M. with Registered Nurse #317 verified Resident #18 and #27 were in the dining room eating and unattended. 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, aphasia, dysphagia, diabetes, dementia, and benign prostatic hyperplasia. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and required supervision with eating. Review of the Medical Nutritional Re-assessment dated [DATE] revealed Resident #18 needed supervision for meals. Review of the June 2022 physician orders revealed Resident #18 had a diet order for a no added salt diet, regular texture, and thin liquids. 365429 Page 4 of 5 365429 06/30/2022 Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 06/27/22 at 5:55 P.M. revealed Resident #27 and #18 were in the dining room eating dinner with no staff supervision. Interview on 06/27/22 at 6:01 P.M. with Registered Nurse #317 verified Resident #18 and #27 were in the dining room eating and unattended. Residents Affected - Few 365429 Page 5 of 5