Health inspection·June 24, 2022

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** 3. Review of the medical record for Resident #3 revealed an admission date of 03/05/22 with diagnoses including osteoarthritis, hypertension, chronic kidney disease, diabetes mellitus and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 for Resident #3 dated 06/12/22 revealed the resident had moderate cognitive impairment with no behaviors. Resident #3 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #3 had an unstageable pressure ulcer with a treatment. Review of the Braden scale (used to determine risk of developing a pressure ulcer) dated 06/13/22 indicated Resident #3 was a low risk for developing pressure ulcers. Review of the pressure ulcer assessment dated [DATE] revealed the assessment to be incomplete and no indication Resident #3 had an unstageable pressure ulcer to his right heel. Review of the physician orders for June 2022 for Resident #3 revealed an order to paint right heel with betadine, wrap with kerlix daily and leave for protection. The June 2022 orders also included an order for Prevalon boots while in bed or chair to bilateral heels. Review of the treatment administration record for May 2022 and June 2022 revealed Resident #3 received the treatment to his right heel daily. Review of the pressure ulcer weekly skin assessment report/tracking log for Resident #3 revealed on 03/28/22 an unstageable pressure ulcer to right heel measured 2 centimeters (cm) by 1.5 cm with purple wound base. On 06/21/22 the unstageable pressure ulcer to right heel measured 0.5 cm by 0.2 cm with a light scab. Review of the plan of care initiated on 03/07/22 with no revisions revealed Resident #3 had the potential for pressure ulcer development related to immobility. The interventions included: cushion to wheelchair/chair dated 03/07/22, protective barrier cream to peri-anal area every shift and as needed dated 03/07/22, gel overlay to bed dated 03/07/22, inform the resident, family/caregivers of any new area of skin breakdown dated 03/07/22, may follow wound care clinic if skin issues occur dated 03/07/22 and turn and reposition every two hours and as needed for comfort as resident will allow dated 05/17/22. The plan of care did not address the actual active unstageable pressure ulcer to Resident #3's right heel. Page 1 of 14 365444 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations of Resident #3 on 06/22/22 at 12:04 P.M., and on 06/23/22 at 9:53 A.M. revealed the resident was not wearing the Prevalon boots as ordered to bilateral lower extremities while in bed and up in his chair. An interview on 06/23/22 at 10:22 A.M. with State Tested Nursing Assistant (STNA) #280 revealed the resident had skin issues to his buttocks and right heel. The STNA said Resident #3 did not have any heel protectors such as Prevalon boots to wear while in bed or up in wheelchair. An interview on 06/24/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #3 had a small scabbed area to right heel that was a blister. The current treatment was swab with iodine, and cover it with a foam dressing. An observation on 06/24/22 at 11:24 A.M. of Resident #3 sitting in his recliner. The resident was not wearing his Prevalon boots, and he proceeded to peel the foam dressing away from his heel. There was a dark dry scabbed area approximately 2 cm in diameter with no redness, drainage or odor noted. Resident #3 then put the dressing back over the area. The dressing was dated 06/23/22 and Resident #3 said someone would be changing it soon. An interview on 06/24/22 at 12:50 P.M. with Registered Nurse (RN) #60 confirmed Resident #3 did not have a care plan in place for the unstageable pressure ulcer to his right heel. Review of the facility policy titled Preventative Skin Care dated 11/27/17 indicated the licensed nurse will document the resident's response to all treatments by completing a weekly progress note to include length, width, depth,odor,drainage, color, pain, and effects of treatment. The RN manager will assess the weekly progress and determine if a new treatment order is needed. Documentation will be done in the medical record and interventions will be incorporated in the resident's care plan. Based on observations, interviews, record reviews, and online guidance, the facility failed to adequately implement care plans and interventions. This affected three residents (#3, #29, and #31) of 20 residents whose care plans were reviewed during the annual survey. The facility census was 49. Findings include: 1. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, stage three chronic kidney disease, hypertension, and systolic heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active care plans for this resident revealed no care plan was implemented for wandering, being at risk for elopement, or the use of a wander guard until 06/21/22. Observation on 06/21/22 at 3:00 P.M. revealed Resident #29 was being assisted onto the elevator by family members when an alarm sounded due to the placement of a wander guard bracelet on the resident. The resident's daughter alerted staff the bracelet should probably be cut off for a while since it had been in place for a couple of weeks. 365444 Page 2 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Registered Nurse (RN) #60 on 06/24/22 at 11:00 A.M. verified there had not been a care plan in place for wandering, being at risk for elopement, or use of a wander guard for Resident #29 prior to 06/21/22. 2. Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including stage four chronic kidney disease, dementia without behavioral disturbances, hypertension, and chronic obstructive pulmonary disorder. Review of the admission MDS assessment, dated 04/23/22, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 07. This resident was assessed to require extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 5/23/22, revealed this resident received dialysis. The only intervention listed was to send a sacked snack with the resident to dialysis. Interview with RN #60 on 06/24/22 at 11:00 A.M. verified the only intervention listed on the resident's care plan was to send a sacked snack with the resident to dialysis and did not contain any additional interventions detailing the plan of care the facility was to provide to the resident regarding dialysis care and treatment. Review of the online guidance from NurseJournal titled Nursing Care Plans Explained (https://nursejournal.org/articles/nursing-care-plans-explained/), modified on 04/28/2022, revealed nursing care plans were a vital part of the nursing process and provided a centralized document of the residents conditions, diagnoses, the nursing teams goals for the resident, and a measure of the residents progress. Nursing care plans were structured to capture all the important information for the nursing team in one place and ensured everything important was documented and available to all team members. Without nursing care plans, communication could become disjointed, and resident information may have been scattered across different records, or nursing staff may have had to rely on verbal handoff's which the new nurse may mishear or even forget. 365444 Page 3 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

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. Based on observation, interview, record review and review of the facility policy the facility failed to revise a resident's plan of care to reflect the pressure ulcer prevention device of Prevalon Boots. This affected one of six residents (#12) reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record for Resident #12 revealed an admission date of 07/20/17 with diagnoses including dementia, unspecified psychosis, weakness and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (3.0) dated 04/08/22 revealed Resident #12 had severe cognitive impairment. Resident #12 was totally dependent on one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #12 had impaired range of motion to bilateral upper extremities. Resident #12 had no skin impairments documented. Review of the physician telephone orders for Resident #12 revealed an order dated 05/03/22 for the resident to wear Prevalon boots while in bed. Staff may remove for dressing and hygiene per resident's tolerance. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022 revealed documentation Resident #12 was wearing Prevalon boots when in bed and may remove for hygiene and dressing. Review of the Braden scale for predicting pressure ulcers score risk dated 5/10/22 revealed Resident #12 was at high risk. The assessment indicated Resident #12's bilateral heels would become reddened in 120 minutes while lying in bed making Resident #12 at risk for pressure ulcer development to bilateral heels. Review of Resident #12's plan of care dated 04/20/22 revealed a plan in place for impaired skin integrity as evidenced by a stage two pressure ulcer to left buttocks related to immobility. The interventions included pressure relieving cushion to wheelchair, protective cream to peri/anal areas every shift and as needed, gel overlay to bed, follow up with local hospital wound care center if skin issues occur, treatment per physician orders and turn and reposition every two hours and as needed for comfort. The plan of care was not revised to include the Prevalon boots to Resident #12's bilateral heels when in bed. Observations of Resident #12 on 06/22/22 at 2:42 P.M., 06/23/22 at 10:02 A.M. and at 2:30 P.M. revealed the resident's heels were lying flat on the bed. Resident #12 did not have on her Prevalon boots as ordered. An interview on 06/23/22 at 2:30 P.M. with State Tested Nursing Assistant (STNA) #440 confirmed Resident #12 did not have on her Prevalon boots, and the STNA could not locate the Prevalon boots in Resident #12's room. An interview on 06/24/22 at 11:19 A.M. with Registered Nurse (RN) #60 confirmed the plan of care was not revised to include the Prevalon boots to bilateral heels when in bed. 365444 Page 4 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility polity titled Preventative Skin Care dated 11/27/17 indicated the RN manager would complete a skin risk assessment for each resident on admission, quarterly, with significant change and acute episode. The Braden's risk scale would be completed on admission weekly times four then monthly, with significant change per Resident Assessment Instrument (RAI) and acute episode. A pressure point skin tolerance test will be completed with the risk scale. All identified risk factors will be documented and interventions will be initiated and documented in the care plan with changes added or deleted as needed. 365444 Page 5 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure pressure prevention devices were in place as ordered by the physician. The affected two of five residents (#12 and #3) reviewed for pressure ulcers. The facility census was 49. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 03/05/22 with diagnoses including osteoarthritis, hypertension, chronic kidney disease, diabetes mellitus and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 for Resident #3 dated 06/12/22 revealed the resident had moderate cognitive impairment with no behaviors. Resident #3 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #3 had an unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) with a treatment. Review of the Braden scale (used to determine risk of developing a pressure ulcer) dated 06/13/22 indicated Resident #3 was a low risk for developing pressure ulcers. Review of the pressure ulcer assessment dated [DATE] revealed the assessment to be incomplete and no indication Resident #3 had an unstageable pressure ulcer to his right heel. Review of the physician orders for June 2022 for Resident #3 revealed an order to paint right heel with betadine, wrap with kerlix daily and leave for protection. The June 2022 orders also included an order for Prevalon boots while in bed or chair to bilateral heels. Review of the treatment administration record for May 2022 and June 2022 revealed Resident #3 received the treatment to his right heel daily. Review of the pressure ulcer weekly skin assessment report/tracking log for Resident #3 revealed on 03/28/22 an unstageable pressure ulcer to right heel measured 2 centimeters (cm) by 1.5 cm with purple wound base. On 06/21/22 the unstageable pressure ulcer to right heel measured 0.5 cm by 0.2 cm with a light scab. Review of the plan of care initiated on 03/07/22 revealed Resident #3 had the potential for pressure ulcer development related to immobility. The interventions included: cushion to wheelchair/chair, protective barrier cream to peri-anal area every shift and as needed, gel overlay to bed, inform the resident, family/caregivers of any new area of skin breakdown, may follow wound care clinic if skin issues occur, and turn and reposition every two hours and as needed for comfort as resident will allow. Observations of Resident #3 on 06/22/22 at 12:04 P.M., and on 06/23/22 at 9:53 A.M. revealed the resident was not wearing the Prevalon boots as ordered to bilateral lower extremities while in bed and up in his chair. An interview on 06/23/22 at 10:22 A.M. with State Tested Nursing Assistant (STNA) #250 revealed the 365444 Page 6 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had skin issues to his buttocks and right heel. The STNA said Resident #3 did not have any heel protectors such as Prevalon boots to wear while in bed or up in wheelchair. STNA #250 confirmed Resident #3 was not wearing his Prevalon boots. An interview on 06/24/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #3 had a small scabbed area to right heel that was a blister. The current treatment was swab with iodine, and cover it with a foam dressing. An observation on 06/24/22 at 11:24 A.M. of Resident #3 sitting in his recliner revealed the resident was not wearing his Prevalon boots, and he proceeded to peel the foam dressing away from his heel. There was a dark dry scabbed area approximately 2 cm in diameter with no redness, drainage or odor noted. Resident then put the dressing back over the area. The dressing was dated 06/23/22 and Resident #3 said someone would be changing it soon. Review of the facility policy titled Preventative Skin Care dated 11/27/17 indicated the licensed nurse will document the resident's response to all treatments by completing a weekly progress note to include length, width, depth,odor,drainage, color, pain, and effects of treatment. The RN manager will assess the weekly progress and determine if a new treatment order is needed. Documentation will be done in the medical record and interventions will be incorporated into the resident's care plan. 2. Review of the medical record for Resident #12 revealed an admission date of 07/20/17 with diagnoses including dementia, unspecified psychosis, weakness and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (3.0) dated 04/08/22 revealed Resident #12 had severe cognitive impairment. Resident #12 was totally dependent on one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #12 had impaired range of motion to bilateral upper extremities. Resident #12 had no skin impairments documented. Review of the physician telephone orders for Resident #12 revealed an order dated 05/03/22 for the resident to wear Prevalon boots while in bed. Staff may remove for dressing and hygiene per residents tolerance. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022 revealed documentation Resident #12 was wearing Prevalon boots when in bed and may remove for hygiene and dressing. Review of the Braden sale for predicting pressure ulcers score risk dated 5/10/22 revealed Resident #12 was at high risk. The assessment indicated Resident #12 bilateral heels would become reddened in 120 minutes while lying in bed making Resident #12 at risk for pressure ulcer development to bilateral heels. Review of Resident #12 plan of care dated 04/20/22 revealed a plan in place for impaired skin integrity as evidenced by a stage two pressure ulcer (defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to left buttocks related to immobility. The interventions included pressure relieving cushion to wheelchair, protective cream to peri/anal areas every shift and as needed, gel overlay to bed, follow up with local hospital wound care center if skin issues occur, treatment per physician orders and turn and reposition every two hours and as needed for comfort. The plan of care was not revised to include the Prevalon boots to Resident #12's bilateral heels when in bed. 365444 Page 7 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0686 Level of Harm - Minimal harm or potential for actual harm Observations of Resident #12 on 06/22/22 at 2:42 P.M., 06/23/22 at 10:02 A.M. and at 2:30 P.M. revealed the resident's heels were lying flat on the bed. Resident #12 did not have on her Prevalon boots as ordered. An interview on 06/23/22 at 2:30 P.M. with STNA #440 confirmed Resident #12 did not have on her Prevalon boots, and the STNA could not locate the Prevalon boots in Resident #12's room. Residents Affected - Few Review of the facility policy titled Preventative Skin Care dated 11/27/17 indicated the licensed nurse will document the resident's response to all treatments by completing a weekly progress note to include length, width, depth,odor,drainage, color, pain, and effects of treatment. The RN manager will assess the weekly progress and determine if a new treatment order is needed. Documentation will be done in the medical record and interventions will be incorporated in to the resident's care plan. 365444 Page 8 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

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 observations, interviews, and record reviews, the facility failed to ensure fall interventions were in place as per the plan of care and failed to ensure evidence of monitoring a resident who was at risk for elopement. This affected two residents (#29 and #44) of the five residents reviewed for falls and elopement during the annual survey. The facility census was 49. Findings include: 1. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, stage three chronic kidney disease, hypertension, and systolic heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active care plans for this resident revealed no care plan was implemented for wandering, being at risk for elopement, or the use of a wander guard until 06/21/22. Review of the physicians orders for Resident #29 revealed there was not an order in place for a wander guard or monitoring of the wander guards placement or function until 06/21/22. Observation on 06/21/22 at 3:00 P.M. revealed Resident #29 was being assisted onto the elevator by family members when an alarm sounded due to the placement of a wander guard bracelet on the resident. The residents daughter alerted staff the bracelet should probably be cut off for a while since it had been in place for a couple of weeks. Interview with Licensed Practical Nurse (LPN) #90 on 06/21/22 at 3:28 P.M. verified there was no documentation of monitoring of the placement or function of Resident #29's wander guard present on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for the for the month of 06/2022. Interview with Registered Nurse (RN) #20 on 06/21/22 at 3:36 P.M. verified there was not an order for a wander guard or to check the placement or function of the wander guard for Resident #29. Interview with RN #60 on 06/24/22 at 11:00 A.M. verified there had not been a care plan in place for wandering, being at risk for elopement, or use of a wander guard for Resident #29 prior to 06/21/22. 2. Record review for Resident #44 revealed this resident was admitted to the facility on [DATE] and had diagnoses including repeated falls, essential tremors, reduced anxiety, and dementia without behavioral disturbances. Review of the admission MDS assessment, dated 05/30/22, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to require extensive 365444 Page 9 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0689 Level of Harm - Minimal harm or potential for actual harm assistance from one staff member for bed mobility, transfers, and toileting. This resident was assessed to have had one fall with injury since admission or the prior assessment. Review of the care plan, dated 05/23/22, revealed this resident was at risk for falls. Interventions included to change the call light button to a touch pad call light and to position the resident's walker within reach. Residents Affected - Few Review of the nurses progress note, dated 06/15/22, revealed the resident was found on the floor next to the commode. The resident reported to the nurse using the call light to summons assistance to the bathroom, however, the call light was not on. The new intervention put into place was to change the call light to a touch pad call light. Observation and interview on 06/23/22 at 2:39 P.M. revealed Resident #44 was sleeping in a recliner located on one side of the room while the resident's walker was located by the wall across the room from the resident. Two button call lights were observed in the resident's room, one connected to the resident's recliner and one connected to the bed. There was no touch pad call light observed in the room. RN #30 verified the resident's walker was not within reach of the resident and there were only push button call lights in the resident's room at the time of the observation. 365444 Page 10 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

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 observation, interviews, record reviews, and review of facility policies, the facility failed to ensure adequate monitoring of a dialysis residents AV shunt. This affected the one resident (#31) who was receiving dialysis while residing in the facility. The facility census was 49. Residents Affected - Few Findings include: Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including stage four chronic kidney disease, dementia without behavioral disturbances, hypertension, and chronic obstructive pulmonary disorder. Review of the admission MDS assessment, dated 04/23/22, revealed this resident had moderately impaired cognation evidenced by a BIMS assessment score of 07. This resident was assessed to require extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 5/23/22, revealed this resident received dialysis. The only intervention listed was to send a sacked snack with the resident to dialysis Review of the physicians order, dated 05/19/22, revealed this resident was scheduled to receive dialysis every Monday, Wednesday, and Friday. Review of the physicians orders revealed there was not an order to assess the AV shunt for thrill and bruit until 06/22/22. Review of the Medication Administration Record, Treatment Administration Record, and progress notes from 05/19/22 through 06/21/22 revealed no documentation of the monitoring of the AV shunt for thrill and bruit. Observation on 06/21/22 at 2:45 P.M. revealed Resident #31 was sitting in a recliner and had an AV shunt present in her left upper arm. Interview with Licensed Practical Nurse (LPN) #600 on 06/22/22 at 10:45 A.M. verified Resident #31 had an AV shunt present and there were not orders to monitor the AV shunt for thrill and bruit. Review of the facility policy titled Hemo-Dialysis, dated 04/20/2008, revealed the facility would monitor the dialysis access site per physician's orders and report any concerns. 365444 Page 11 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide an appropriate diagnosis for the use of an antipsychotic and failed to discontinue an antianxiety medication due to non-use. This affected two residents(Resident #44 and Resident #201) of five residents reviewed for unnecessary medications. The facility census was 49. Findings include: 1. Record review of Resident #201 on 06/22/22 at 3:28 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: left femur fracture, dysphagia, muscle weakness, anemia, depression, anxiety, hypertension, carotid artery stenosis, gastroenteritis, chronic kidney disease, diarrhea, and transient ischemic attacks. This resident is currently alert and oriented to person, place, and time per admission assessment and nursing notes as this resident does not have an active BIMS score as this resident has been residing in the facility for approximately 2 days. Review of Physician Orders revealed this resident is receiving the following medications: Olanzapine 2.5mg PO daily at bedtime for mood. Review of current medical diagnoses revealed this resident does not have an active diagnosis of mood disorder or any other psychiatric disorder. Interview with Registered Nurse #40 on 06/23/22 at 09:17 A.M. verified this resident does not have a current diagnosis of mood disorder or any other psychiatric disorder. 2. Record review for Resident #44 revealed this resident was admitted to the facility on [DATE] and had diagnoses including essential tremors, insomnia, dementia without behavioral disturbances, and anxiety. Review of the admission MDS assessment, dated 05/30/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 05/26/22, revealed an order to administer Ativan (an antianxiety medication) 0.5 milligrams (mg) every hour of sleep as needed. Interview with Registered Nurse (RN) #30 on 06/23/22 at 2:12 P.M. verified Resident #44 has an active order for Ativan to be administered as needed which did not contain a stop date. 365444 Page 12 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure medications were stored appropriately and provided for the use intended. This affected one resident (#48) out of the 49 residents observed during the annual survey. The facility census was 49. Findings include: Record review for Resident #48 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, dementia without behavioral disturbances, anxiety, insomnia, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/05/22, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the care plan, dated 06/13/22, revealed this resident had asthma and shortness of breath. Interventions included to give aerosols or bronchodilators as ordered. Review of the facility Self Administration of Medication assessment, dated 06/06/22, revealed this resident was unaware of medications, doses, etc. and nursing staff was to administer all medications. Review of the active physicians orders revealed there were no orders to leave medications or inhalers at bedside. Observation and interview on 06/21/22 at 10:53 A.M. revealed Resident #48 was sitting in a recliner and had an inhaler located within easy reach on the tray table located directly beside the recliner. Resident #48 picked up the inhaler and stated it did not seem to be working correctly and was not able to read the label. The label was observed to be severely faded and contained the the wording Albuterol Aer HFA inhale two puffs by mouth every four hours as needed for dyspnea. Interview with Licensed Practical Nurse (LPN) #90 on 06/21/22 at 11:08 A.M. revealed staff provided the inhaler to Resident #48 as a placebo due to the resident's anxiety if the inhaler was not there. Observation on 06/22/22 at 10:05 A.M. revealed Resident #48 was sitting in a recliner and had the inhaler located within easy reach on the tray table located directly beside the recliner. Observation and interview on 06/23/22 at 12:55 P.M. with Registered Nurse (RN) #30 verified there was an inhaler lying on the table within easy reach of Resident #48. RN #30 picked up the inhaler and took it out of the room as she informed Resident #48 she would have to check and see what the inhaler was and if it could be left in the room. RN #30 then verified the inhaler was labeled Albuterol Aer HFA and demonstrated the inhaler being depressed with aerosolized medication coming out of the inhaler. RN #30 then checked the physician's orders for Resident #48 and verified there was no order 365444 Page 13 of 14 365444 06/24/2022 Hill View Retirement Center 1610 28th Street Portsmouth, OH 45662

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the resident to have the inhaler at bedside. RN #30 stated she was unsure as to why the resident had the inhaler in room. Review of the facility policy titled Self Administration of Medications, dated 06/08/10, revealed residents would not be allowed to administer or retain medications in their rooms unless ordered so by the physician and approved by the care planning team. 365444 Page 14 of 14