Health inspection·November 21, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #12 revealed an admission date of [DATE]. Review of the electronic medical record revealed Resident #12 had physician orders for a Do Not Resuscitate Comfort Care (DNRCC) Advance Directive. Review of the hard chart revealed the resident had no signed DNRCC form in the medical record. Interview conducted on [DATE] at 1:00 P.M. with Registered Nurse (RN) #462 stated the resident was a DNRCC. RN #462 stated if the resident coded at that time, she would verify in the Electronic Health Record (EHR) the resident code status and look in the hard chart to verify signed form. RN #462 verified there was no signed form in the resident hard chart and if the resident coded at that time, she would perform Cardiopulmonary Resuscitation (CPR) due to no signed DNR form in the medical record. Review of policy titled Social Services Policy/Procedure Manual, dated [DATE], stated Upon admission, should the resident have an Advance Directive, copies will be made and placed on the chart as well as communicated to the staff. Based on observation, interview, and record review the facility failed to have advanced directives properly documented. This affected two (Resident #4 and Resident #12) of 22 residents reviewed for advanced directives. The census was 107. Findings include: 1. Review of Resident #4's medical records revealed an admission date of [DATE]. Review of the electronic health record revealed a Do Not Resuscitate - Comfort Care Arrest (DNRCCA) order entered on [DATE]. Observation on [DATE] at 12:39 P.M. revealed no physician signed DNRCCA form nor any other indication in the resident chart. Interview on [DATE] at 12:55 P.M. Licensed Practical Nurse (LPN) #480 stated if the resident coded she would look in the electronic health record for the code status, then verify signed DNRCCA in the hard chart. LPN #480 verified there was no signed DNRCCA form completed in the resident chart. LPN #480 further stated the signed copy should be in the chart. As a result LPN #480 stated she would then perform chest compressions and attempt to resuscitate the resident due to the lack of signed DNRCCA form in the hard chart. Page 1 of 10 365469 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

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 medical record review, observation, staff and resident interviews, the facility failed to fully complete the required quarterly Minimum Data Set (MDS) assessment. This affected one (Resident #79) of twenty-two residents reviewed during the investigation stage of the annual survey. The facility census was 107. Residents Affected - Few Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with diagnoses including respiratory failure, dysphagia, abnormal posture, chronic obstructive pulmonary disease, epilepsy, major depressive disorder, anxiety disorder, and dependence on dialysis and respirator. Review of last quarterly MDS assessment dated [DATE] revealed Section C- Cognitive Patterns including the Brief Interview of Mental Status (BIMS) was not completed and noted as not assessed on all sections of the mental status assessment. Review of the Social Service Progress Note dated 10/25/19, competed by Social Services (SS) #474 documented the psychosocial assessment for the quarterly MDS dated [DATE] was attempted on 10/25/19 and Resident #79 was receiving ventilator treatment, is non-verbal and unable to complete BIMS. Observation and interview conducted on 11/20/19 at 5:05 P.M., Resident #79 was observed in bed, with ventilator in place. Resident #79 was interviewed during the annual survey, and was observed to answer questions appropriately and a reliable source of information. Interview conducted on 11/21/19 at 8:01 A.M. with the facility Director of Nursing (DON) verified Resident #79's MDS Section C assessment dated [DATE] was noted as not assessed. The DON verified Resident #79's medical record contained no documentation that additional attempts were made to complete assessment prior to SS #474's attempt on 10/25/19. DON verified Resident #79 was typically alert and able to answer questions with no issues. During interview conducted on 11/21/19 at 8:30 A.M., SS #466 stated she was aware BIMS assessments are required to be completed fully for residents. SS #466 stated she had attempted to complete the assessment for the resident, however had no documentation of verification and/or completed the required assessment. SS #474 stated he was new to the facility and attempted to see the resident on 10/25/19. SS #474 verified he did not complete the assessment as required, stating the resident was not able to talk to him, so the assessment wasn't completed. SS #474 stated he was not trained on who to complete the assessment, if they resident is non-interviewable/or unable to complete the assessment. 365469 Page 2 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement baseline care plans that were person centered and included the minimum healthcare information necessary to care for the residents. This affected three (Residents #3, #12 and #88) reviewed during the annual survey. The facility census was 107. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 08/08/18. Medical diagnoses included but not limited to, chronic respiratory failure with hypoxia, abnormal posture, ventilator status, tracheostomy status, muscle weakness, dementia, type two diabetes mellitus, aphasia, anxiety, adult failure to thrive, gastrostomy status, persistent vegetative state, gangrene, and congestive heart failure. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognition was severely impaired and the resident was comatose. Review of Resident #3's medical chart revealed no baseline care plan. Interview on 11/21/19 at 12:19 P.M. with the Director of Nursing (DON) who stated the facility could not locate a baseline care plan for Resident #3. 2. Review of the medical record for Resident #12 revealed an admission date of 05/30/19. Medical diagnoses included but not limited to, respiratory failure, ventilator status, tracheostomy status, end stage renal status, atrial fibrillation, pressure ulcer, anemia, depression, peripheral vascular disease, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12's cognition was intact. Interview on 11/21/19 at 12:19 P.M. with the Director of Nursing (DON) who stated the facility could not locate a baseline care plan for Resident #12. 3. Review of the medical record for Resident #88 revealed an admission date of 10/29/19. Medical diagnoses included but not limited to, enterocolitis due to clostridium difficile, end stage renal disease, osteoarthritis, muscle weakness, depression, type two diabetes, hypertension and atrial fibrillation. Review of the admission MDS assessment dated [DATE] revealed Resident #88's cognition was intact. Resident #88 was noted on the MDS under Section O to have received Dialysis. Interview on 11/21/19 at 8:56 A.M. with the Assistant Director of Nursing (ADON) who reviewed the baseline care plan which was in the resident's chart and he verified he did not see that the baseline care plan addressed the resident's dialysis needs. 365469 Page 3 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. Medical record review for Resident #12 revealed an admission date of 05/30/19. Medical diagnoses included but not limited to, respiratory failure, ventilator status, tracheostomy status, end stage renal status, atrial fibrillation, pressure ulcer, anemia, depression, peripheral vascular disease, and anxiety. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12's cognition was intact. Review of the medical record for Resident #12 revealed no care conferences had been held. Interview on 11/20/19 at 4:56 P.M. with the Administrator) who stated the facility did not have the care conferences for this resident. The facility was not able to reach her family via telephone but that did not impact the resident. Based on medical record review, staff and resident interviews and review of facility policy, the facility failed to conduct appropriate interdisciplinary team (IDT) care plan meetings (care conferences) as required. This affected five (Residents #4, #7, #12, #30, and #97) of five reviewed for care planning during the annual survey. The facility census was 107. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with a diagnoses including paraplegia, personality disorder, hypertension, bipolar, chronic pain syndrome, and pressure ulcers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact with rejection of care behaviors one to three days during the seven day look back period. Review of Social Services Progress Notes dated 11/19/19, 08/21/19, 08/14/19, 04/12/19, 01/10/19 revealed the care conference offered to resident and the resident declined. On 10/10/19, the care conference was offered to resident and brother, and both declined. Further review of the medical record revealed no documentation the IDT still conducted the required comprehensive assessments, with the required staff, to review appropriate care. Interview conducted on 11/19/19 at 11:16 A.M., Resident #7 stated he use to be invited to care conference meetings, but he was unsure of when they last had one. Interview conducted on 11/20/19 at 2:48 P.M. the facility Administrator verified the facility did not hold IDT care conference for Resident #7 with a appropriate staff. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including dependence on respirator, tracheostomy, severe morbid obesity, epilepsy, heart failure, asthma, chronic pain, major depressive disorder, anxiety disorder, type two diabetes, and chronic obstructive pulmonary disease. 365469 Page 4 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) 09/18/19 revealed Resident #30 was cognitively intact with rejection of care noted one to three days during the look back period. Review of the Social Service Progress Notes dated 09/18/19, 05/01/19, 02/22/19, and 11/22/18 revealed the resident was offered a care conference and declined. The medical record contained no documentation verification the facility held an IDT care plan meeting with the required staff, to review Resident #30's care. Interview conducted on 11/19/19 at 9:50 A.M., Resident #30 stated the facility use to have care conferences, but she had no been invited to one in a long time. Interview conducted on 11/20/19 at 2:47 P.M. the Administrator stated the facility conducted a care conference on 11/04/19 that the resident and her mother were invited to, however also verified the conference held did not include the required staff including but not limited to, the attending physician and/or non-physician practitioner, and nurse aid with responsibility for the resident. 3. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses including dependence on renal dialysis, liver transplant, type two diabetes, mood disorder, constipation, heart failure, and stage 5 chronic kidney disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitive intact, with noted delusions, behavioral symptoms not directed towards others and rejection of care noted one to three days during the look back period. Interview conducted on 11/19/19 at 10:57 A.M., Resident #97 stated she had not been invited to attend a care plan meeting and/or care conference since admission to the facility. Review of Nursing progress Note dated 11/12/19 revealed a care conference was held, over the phone, with Resident #97's son and the social worker. Interview conducted on 11/20/19 at 3:09 P.M., the facility Administrator stated Resident #97's son is very specific, and had requested weekly conferences over the phone. Administrator verified Resident #97 was cognitively intact, and the facility was unable to provide any verification the resident was invited or even addressed regarding care conferences, and/or care conferences only with her son. 5. Review of Resident #4's medical records revealed an admission date of 06/07/19 with diagnoses including acute and chronic respiratory failure, dependence on respirator, tracheostomy, type two diabetes mellitus, dementia, seizures, atherosclerotic heart disease of native coronary artery, hypertension, protein-calorie malnutrition, dysphagia, and chronic obstructive pulmonary disease. Review of minimum data set (MDS) dated [DATE] revealed resident had moderate cognitive impairment. Resident #4 required extensive to total assistance of one or two people for all activities of daily living. Review of resident's social work records and progress notes revealed no documentation of care conferences being held for the resident. Interview on 11/20/19 at 8:00 A.M. Administrator stated the facility had a new social services 365469 Page 5 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0657 staff and they had discovered care conferences were not being done consistently. The Administrator further verified that the facility did not have and care conference documentation for Resident #4. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365469 Page 6 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to administer medication to residents within an error rate less than five percent. This affected one (Residents #353) of five residents reviewed for medication administration during the annual survey. The facility census was 107. Residents Affected - Few Findings include: During medication administration reviews, twenty-five medication administration opportunities were observed with two noted errors, resulting in a medication administration facility error rate of 8 percent. Review of the medical record revealed Resident #353 was admitted to the facility on [DATE] with diagnoses including hyperglycemia, hypotension, end stage renal disease, dependence on renal dialysis, and type two diabetes. Review of the physician orders revealed the resident was ordered Midodrine 5 milligram (mg) tablet with meals, for hypotension and hold if the systolic blood pressure is greater than 110 mm/Hg. Resident #353 was also ordered insulin five units with meals, and additional sliding scale insulin dependent on blood sugar. Observation and interview conducted on 11/20/19 at 11:43 A.M. during medication administration review revealed Resident #353 was observed in his room with her lunch tray on the overbed table. Resident #353 was eating his lunch meal. LPN #408 was observed at that time, checking Resident #353's blood sugar with a glucometer and providing the ordered Humalog (insulin) with additional six units sliding scale for blood sugar of 206. When questioned regarding LPN #408 checking resident's blood sugars after they had already began eating and providing ordered insulin, LPN #408 stated she does them when they are scheduled, whatever time they are due. LPN #408 was also observed during that time, checking Resident #353's blood pressure and providing his ordered Midodrine. During medication administration record (MAR) reconciliation review, Resident #353's documented blood pressure for 11/20/19 was a systolic pressure of 167, which is out of specified parameter. Further review of the MAR revealed the resident was also provided the Midodrine on twice 11/17/18 with systolic pressures of 112 and 121, 11/19/19 with systolic pressure of 144, on 11/20/19 with systolic pressure of 133, and on 11/21/19 with systolic pressure of 167. Interview conducted on 11/20/19 at 12:23 P.M. with Registered Nurse (RN) #656 state she would expect for the staff to check blood sugars prior to the resident eating, when providing insulin. Review of the facility policy titled Medication Administration, dated June 2017 revealed insulin is a high risk drug and warrants additional precautions for the safe and effective administration. Medication will be administered within accepted standards of practice. 365469 Page 7 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to check blood sugars and give ordered insulin prior to meals and failed to provide Midodrine (used to increase blood pressure) within the required parameters, both resulting in significant medication errors. This affected two (Residents #73 and #353) of 26 resident the facility identified as receiving insulin, and also affected one (Resident #353) of nine residents the facility identified as receiving Midodrine. The facility census was 107. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including muscle weakness, type one diabetes, and need for assistance with personal care. Review of the physician orders revealed Resident #73 was ordered Novolog Insulin, 4 units injection before meals. Observation and interview conducted on 11/20/19 at 11:27 A.M. during medication administration review revealed Resident #73 was observed in her room with her lunch tray on her overbed table. Resident #73 stated she was finished with her meal. Licensed Practical Nurse (LPN) #408 was observed at that time, checking Resident #73's blood sugar with a glucometer and providing the ordered Novolog insulin. 2. Review of the medical record revealed Resident #353 was admitted to the facility on [DATE] with diagnoses including hyperglycemia, hypotension, end stage renal disease, dependence on renal dialysis, and type two diabetes. Review of physician orders revealed Resident #353 was ordered Midodrine 5 milligram (mg) tablet with meals for hypotension, and to hold if the systolic blood pressure is greater than 110. Resident #353 was also ordered insulin 5 unit with meals, and additional sliding scale insulin dependent on blood sugar. Observation and interview conducted on 11/20/19 at 11:43 A.M. during medication administration review revealed Resident #353 was observed in his room eating his lunch meal. LPN #408 was observed at that time, checking Resident #353's blood sugar with a glucometer and providing the ordered Humalog (insulin) with additional six units sliding scale for blood sugar of 206. When questioned regarding LPN #408 checking residents blood sugars after they had already began eating and providing ordered insulin, LPN #408 stated she does them when they are scheduled, whatever time they are due. LPN #408 was also observed during that time, checking Resident #353's blood pressure and providing his ordered Midodrine. During medication administration record (MAR) reconciliation review, Resident #353's documented blood pressure for 11/20/19 was a systolic pressure of 167, which is out of specified parameter. Further review of the MAR revealed the resident was also provided the Midodrine on twice 11/17/18 with systolic pressures of 112 and 121, 11/19/19 with systolic pressure of 144, on 11/20/19 with systolic pressure of 133, and on 11/21/19 with systolic pressure of 167. Interview conducted on 11/20/19 at 12:23 P.M. with Registered Nurse (RN) #656 state she would 365469 Page 8 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0760 expect for the staff to check blood sugars prior to the resident eating, when providing insulin. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Medication Administration, dated June 2017, revealed insulin is a high risk drug and warrants additional precautions for the safe and effective administration. Medication will be administered within accepted standards of practice. Residents Affected - Few 365469 Page 9 of 10 365469 11/21/2019 Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, staff interview, and review of facility policy, the facility failed to date open vials of Influenza vaccine and Tuberculin Purified Protein Derivative(PPD) and the facility failed to dispose of outdated Prostat (protein supplement). This had the potential to affect all 107 residents residing in the facility. Findings include: Medication storage observation and interview conducted on 11/20/19 at 8:58 A.M. with Licensed Practical Nurse (LPN) #486 revealed an open/undated vial of influenza vaccine noted in the L-Hall medication storage refrigerator. LPN #486 verified the vial was open and undated, and should have been dated when it was opened. Medication storage observation and interview conducted on 11/20/19 at 10:37 A.M. with LPN # 480 revealed two bottle of Prostat (protein supplement) expiration dated 06/06/19 and the other dated 10/02/19 in the F-Hall medication cart, and a open/undated insulin pen. LPN #480 verified the Prostat was out of expiration date, and should had been disposed of, and the insulin pen should have been dated when opened. Further review of medication storage conducted at 10:52 A.M. with LPN #480, of the E/F medication storage room, revealed two bottles of Tuberculin PPD. LPN #480 stated the Tuberculin PPD was used on resident's and staff member to check for Tuberculosis when they are admitted /hired to the facility. LPN #480 verified the bottles were both opened and undated, and should have been dated upon opening. Interview conducted on 11/20/19 at 12:23 P.M. with Registered Nurse (RN) #656 stated she would expect all vial medications to be dated upon opening and disposed of within the required time frames, as applicable. Review of the facility policy titled, Medication Storage, dated June 2017, revealed outdated medication are immediately removed from stock, and disposed of accordingly. Staff should ensure the opened date is documented on the vial or pen. 365469 Page 10 of 10