Health inspection·August 23, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, family interview, staff interview, and policy review, the facility failed to ensure residents that were dependent on staff for personal care received the assistance needed to complete oral hygiene care. This affected three residents (#1, #12, and #81) of four residents reviewed for activities of daily living (ADL's). Residents Affected - Few Findings include: 1. A review of Resident #81's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, Parkinson's disease, adult inset diabetes mellitus, and major depressive disorder. A review of Resident #81's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty with hearing, without the use of a hearing aide, and his speech was clear. He was sometimes able to make himself understood and was sometimes able to understand others. His cognition was severely impaired, but was not known to reject care. He required an extensive assist of two for transfers and personal hygiene. A review of Resident #81's care plans revealed he had a care plan in place for an ADL self-care performance deficit related to Alzheimer's Disease, cognitive impairment, generalized weakness, and Parkinson's disease. The care plan was initiated on 07/27/23 and revised on 07/29/23. His goal was for his ADL needs to be met through the next review. The interventions included a one person assist for personal hygiene. His care plans did not indicate he was known to be non-compliant with oral care. A review of Resident #81's task tab under the electronic health record (EHR) revealed the staff were documenting under an oral care task when that care was being provided. A review of the oral care task report for the past 30 days (07/27/23 thru 08/21/23) revealed the resident was documented as having received oral care once or twice a day on a daily basis since his admission. The times the oral care was documented as having been completed was on the day shift (6a-2p) and the afternoon shift (2p-10p). On 08/21/23 at 10:40 A.M., an interview with Resident #81's family member revealed he had never seen the resident have a toothbrush in his room that was being used to provide him with oral care. He denied his father was capable of communicating much in the way of his needs. He had his own natural teeth and would need the assistance from the staff to provide him with oral care. Up until about a week ago, the resident did not look like he was getting his teeth brushed. He felt the resident's teeth looked a little better now, but he was not sure what toothbrush they were using to provide the resident with oral care. He again stated he had never seen a toothbrush in the resident's room to be Page 1 of 7 365474 365474 08/23/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0677 used for oral care. Level of Harm - Minimal harm or potential for actual harm On 08/21/23 at 10:50 A.M., an observation of Resident #81 noted him to be in the dining room where he remained after previously participating in an activity. His teeth were noted to be a little discolored and he had a film like coating over them. No halitosis was noted, but the resident did not talk much when spoken to, so it was difficult to assess if halitosis was present. Residents Affected - Few On 08/21/23 at 11:39 A.M., Registered Nurse (RN) #11 was asked to accompany the surveyor to Resident #81's room to check and see what oral care supplies the resident had on hand. She checked a drawer in the nightstand by his bed and located a tube of toothpaste, a toothbrush that was still in the box it was packaged in, and a toothbrush holder that was empty. She verified that was a new toothbrush that had not been used and the tube of toothpaste did not appear to have anything out of it, as it did not appear to have been squeezed. On 08/21/23 at 11:56 A.M., an interview with State Tested Nurse Aide (STNA) #23 revealed Resident #81 required total assist for his personal care, to include oral care. She indicated he allowed oral care at times, but had been non-compliant that morning, despite the task tab documentation for oral care showing that it had been done. She reported the resident would get antsy with care and had his own teeth that they tried to brush the best they could. She denied he had a toothbrush over the weekend and reported she had thrown his previous toothbrush away last Thursday (08/17/23), due to it having bite marks on it. She indicated someone must have brought a toothbrush in since then. She confirmed the toothbrush he had in his room was unused and was still in the box it came in. She also confirmed the tube of toothpaste he had showed no signs of it being previously used. They (aides) were expected to inform the nurses when a resident refused care, such as not allowing oral care to be provided, and it would be documented. She would re-approach a resident if they refused care to see if they would allow it at a later time when the resident was given the opportunity to calm down. She was asked to come get the surveyor, after the resident ate his lunch, to demonstrate his cooperativeness with oral care, when attempted. On 08/21/23 at 2:10 P.M., a follow up observation of Resident #81 noted him to be lying in his bed with his eyes closed. His oral care supplies were checked and the toothbrush had been removed from the box and was now being stored in his toothbrush holder. The toothbrush holder was opened and the toothbrush was noted to be wet and had debris in it. It smelled of mint when the toothbrush holder was opened. The resident's teeth were not visible as he was resting and had mouth closed. On 08/21/23 at 2:36 P.M., an interview with STNA #36 revealed Resident #81 required total assist of one for his personal care. He reported the resident was typically up for his evening meal and they would lie him down in bed soon after. The resident's son was usually there for the evening meal on most days. He indicated personal care would be provided to the resident when they laid him down as needed. He stated if his face and hands were soiled following the evening meal they would wash it off and change his clothes. He believed the resident had his own teeth. Oral care for the resident would be done by the night shift. He denied the afternoon shift provided oral care to the residents, as was being documented under the task tab for oral care. He indicated they had 22 residents on that hall that required a check and change every two hours. They did not have time on the evening shift to do oral care when putting residents in bed. On 08/22/23 at 9:10 A.M., a follow up interview with STNA #23 revealed she was able to get the SR to brush his teeth yesterday afternoon, after he finished his lunch and was taken back to his room. She did not come and get the surveyor, as was requested. She stated she brushed his teeth that 365474 Page 2 of 7 365474 08/23/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning too, before they took him out for breakfast. She denied he gave her any trouble when brushing his teeth either time. A review of the facility's policy on ADL's revealed a resident, who was unable to carry out activities of daily living, would receive the necessary services to maintain good grooming, personal and oral hygiene. The policy was last reviewed on 01/01/22. 2. A review of Resident #1's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting his right dominant side, contracture of the right hand, abnormalities of gait and mobility, muscle weakness, lack of coordination, and malaise. A review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not noted to reject any care during the seven day assessment period. He was dependent on two for transfers and required an extensive assist of two for personal hygiene (combing hair, brushing teeth, shaving). A review of Resident #1's care plans revealed he had a care plan in place for an ADL self-care performance deficit related to a CVA (stroke) with right sided deficit. The care plan was initiated on 07/28/23. The goal was for the resident's ADL needs to be met. The interventions included providing one person assist for personal hygiene and to encourage participation in daily care and provide positive reinforcement for activities attempted and/ or partially achieved. He also had a care plan for being at risk for dental problems related to needing assistance with oral care. That care plan was initiated on 08/10/23. The goal was for the resident to accept mouth care at least daily. The interventions included encouraging the resident to complete oral hygiene at least daily, provide assistance as needed, and review with the resident the risks of refusing oral care versus the benefits of performing oral care. A review of Resident #1's task tab under the EHR revealed the staff were documenting oral care being provided per the plan of care. The tasks tab for oral care in the past 30 days (07/24/23 thru 08/22/23) revealed the staff documented providing oral care for the resident once or twice a day on a daily basis. The report showed oral care was not provided on one of the two shifts three times that 30 day period and the resident was documented as having refused oral care three times during that same 30 day period. On 08/22/23 at 9:19 A.M., an interview with Resident #1 revealed yesterday (08/21/23) was the first time since he had been there that the staff brought in a bucket with toothpaste, toothbrush, and mouthwash for him to use to perform oral care. He asked them why they were bringing that to him and was told it was because the State was there in the building. He felt he was capable of performing his own oral care, but would be dependent on the staff to set him up with the proper supplies to do so. He denied the staff had ever provided him with set up help to do his own oral care, nor have they asked him if he wanted to do it. 3. A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following a CVA affecting her left dominant side, abnormalities of gait and mobility, fatigue, muscle weakness, lack of coordination, and need for assistance with personal care. A review of Resident #12's quarterly MDS assessment dated [DATE] revealed the resident did not have 365474 Page 3 of 7 365474 08/23/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any communication issues and was cognitively intact. She was totally dependent on staff and required the assist of two for transfers and required an extensive assist of two for personal hygiene. A review of Resident #12's active care plans revealed she needed ADL assistance related to a stroke with left side deficits. The care plan was initiated on 01/06/23. The goal was for the resident to maintain her abilities in ADL care. The interventions included providing an extensive assist of one to two staff members for personal hygiene and oral care. The care plan indicated the resident had upper dentures and natural teeth on the bottom. She also had a care plan for being at risk for oral/ dental health problems related to requiring assistance with oral care. That care plan was initiated on 01/06/23. The goal was for the resident to comply with mouth care at least daily. The interventions included providing mouth care as per her ADL personal hygiene care plan. The care plans did not show she had been known to refuse oral care. A review of Resident #12's task tab in the EHR revealed the staff were documenting oral care as having been provided to the resident one to two times daily in the past 30 days (07/24/23- 08/21/23). She was indicated to have refused only once on 07/29/23. On 08/22/23 at 12:20 P.M., an observation of Resident #12 noted her to have some discoloration/ stains on her teeth in her front lower jaw. There was some plaque build-up along the gum line of those front lower teeth. On 08/22/23 at 12:20 P.M., an interview with Resident #12, at the time of the observation, revealed she did not receive the assistance she required with oral care. Her daughter would typically brush her teeth when she visited her in the evenings, but she denied the staff would brush them or even offer. She indicated she had full use of her right arm and felt she may be able to brush them herself, if the staff would help set her oral care supplies up for her. She denied the staff offered to do that as part of the personal care she received in the mornings or at night when going to bed. She would like that to be offered to her twice a day, but hated to ask anyone to do anything for her. She became tearful at that time. This deficiency represents non-compliance investigated under Master Complaint Number OH00145425. 365474 Page 4 of 7 365474 08/23/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on a closed record review, review of a facility incident report related to a medication error, review of an employee file, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one resident (#84) of three residents reviewed for medication administration. Findings include: A review of Resident #84's closed medical record revealed he was admitted to the facility on [DATE] for short respite stay that was to only be over the weekend. He remained in the facility through 07/31/23, when he was transferred to the emergency room directly from his day program set up through the Ohio Department of Developmental Disabilities. He did not return to the facility as he was re-admitted to the hospital on [DATE]. His diagnoses included cerebral palsy, quadriplegia, seizure disorder, neuromuscular scoliosis of the thoracic region, neurogenic bladder, presence of a supra-pubic catheter, and a urinary tract infection (UTI). A review of Resident #84's hospital continuity of care/ after visit summary from the hospital revealed he was to start taking Colace (a stool softener) 100 milligrams (mg) by mouth (po) twice a day, Dulcolax (a laxative) 10 mg suppository one rectally daily, Lactulose (a laxative) 30 milliliters (ml) three times a day as needed (prn) for constipation, and a Fleets enema rectally every day prn for constipation. The continuity of care/ after care visit summary revealed he was to continue to take the following medications: Albuterol 2.5 mg/ 3 ml (0.083%) inhalation solution per nebulizer every six hours prn for wheezing or shortness of breath, Cranberry tablets 400 mg po twice daily, Cymbalta (an anti-depressant) 60 mg po every day, Pepcid (an antacid) 20 mg po twice daily, Allegra (antihistamine)180 mg po every day, Ibuprofen (an anti-inflammatory) 600 mg po every six hours prn for mild pain, Lamictal (an anti-convulsant) 200 mg po twice a day for spastic quadriplegic cerebral palsy, Seroquel (an ant-psychotic) XR 150 mg po every night at at bedtime, Senna (a laxative) 8.6 mg po twice a day, and Zanaflex (a muscle relaxant) 4 mg po three times a day. A review of Resident #84's physician's orders for the date range of 07/27/23 through 07/31/23 revealed ancillary orders were added on 07/28/23. All the medications ordered for the resident upon his admission to the facility as included in the hospital's continuity of care/ after visit summary were not added to his physician's orders until 07/30/23. A review of Resident #84's medication administration record (MAR) for July 2023 revealed he did not receive any medication ordered for him upon his admission until 07/30/23. No medications had been administered to him on 07/28/23 or 07/29/23. The first documented administration of his medications started the morning of 07/30/23. He was not given his Lamictal that was ordered for his seizure disorder until the evening of 07/30/23 and did not receive a dose of Tizanidine (Zanaflex) ordered for his Cerebral Palsy and related diagnoses until the evening of 07/30/23. His MAR's did show the resident had been given a dose of Ibuprofen 600 mg that was ordered every six hours on a prn basis for pain on 07/30/23 at 9:42 A.M. A second dose of the prn Ibuprofen was administered on 07/31/23 at 8:10 A.M. The dose administered on 07/30/23 at 9:42 A.M. was indicated to be effective. The dose given on 07/31/23 at 8:10 A.M. was indicated to be unknown as he was out of the facility at the time a follow up on his pain was required. 365474 Page 5 of 7 365474 08/23/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0760 Level of Harm - Minimal harm or potential for actual harm A review of Resident #84's progress notes revealed a nurse's note dated 07/31/23 at 10:18 A.M. that indicated the facility's Director of Nursing (DON) spoke with the resident's sister regarding the resident's medication error. The resident was indicated to have been sent to the emergency room (ER) from day program due to signs and symptoms of pain. He was admitted to the hospital for a UTI. The resident had been previously hospitalized for a UTI, prior to his admission to the facility. Residents Affected - Few A review of an incident report dated 07/31/23 for a medication error occurring to Resident #84 revealed medication orders were not initiated upon Resident #84's admission to the facility on [DATE]. The person preparing the report was the facility's DON. The error was noticed on 07/31/23 in the morning. Two doses of medications were omitted. The resident was unable to give a description of the incident. Immediate action taken by the facility included entering the medications into the medication administration record (MAR). The physician was notified of the error and no changes were made to the resident's orders. The resident was indicated to be without adverse effects from the error and no change in behavior or seizure activity was noted. A review of Licensed Practical Nurse (LPN) #67's employee file revealed a performance improvement form was completed on 07/31/23. The reason for counseling/ corrective action was the resident (Resident #84) was admitted to the facility on [DATE] in the early afternoon. Medication orders were not entered into the facility's computer software program (PointClickCare/PCC) resulting in medications being omitted x 48 hours. The expected level of performance was for orders to be entered into PCC upon a resident's admission to ensure timely delivery from the pharmacy. The corrective action taken was a written warning. LPN #67 signed the performance improvement form on 07/31/23. On 08/22/23 at 11:07 A.M., an interview with the DON confirmed Resident #84's medications were not ordered upon his admission to the facility on [DATE]. She stated she was doing a random audit at home on Sunday (07/30/23), when she noticed he did not have any medications ordered. She called into the facility and spoke with the nurse that admitted him. It was determined that the nurse had entered the ancillary orders into the computer on 07/28/23, but she forgot to enter his medications, after the resident arrived. They typically entered the ancillary orders ahead of the resident's arrival, but often did not have access to their medication list until the resident's arrival (when the continuity of care form was sent with them). The resident's medications were not entered into the computer until 07/30/23, in which he started to receive his ordered medication on 07/30/23 when they were either pulled from the contingency supply box or after being delivered by the pharmacy. She indicated they completed immediate correction interventions for past non-compliance, since they self identified and addressed the issue. She did a whole house audit for those that had recently been admitted to ensure all residents had medications ordered upon their admission. They disciplined the nurse involved with a written warning (who no longer worked at the facility), educated all nursing staff, and continued to conduct weekly audits of the past weeks admissions to ensure continued compliance. They were reviewing their findings in the weekly Ad hoc QAPI meetings. She denied the resident showed any signs of being in pain or any other discomforts when he left for his day program on 07/31/23. She recalled the resident was smiling, laughing, and waving when he left the facility and was acting his normal self. She stated he was re-admitted to the hospital with a UTI, which he had prior to his admission to the facility on [DATE]. A review of the facility's policy on Medication Reconciliation revised 01/01/22 revealed the facility reconciled medications upon admission and as needed. The definition of medication reconciliation indicated it referred to the process of verifying that the resident's current medication list matched the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay. Medication reconciliation involved collaboration with the 365474 Page 6 of 7 365474 08/23/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident/ representative and multiple disciplines, including admission liaisons, licensed nurses, physician's, and pharmacy staff. The pre-admission process was to include obtaining a current medication list from the referral source and to obtain current medication/ admission orders. The admission process was to include verifying the resident information was received, compare the orders to hospital records, follow procedures on the medication reconciliation form, and order medications from the pharmacy in accordance with the facility's procedure for ordering medications. The deficiency was corrected on 07/31/23, after the facility implemented the following corrective actions: • On 07/30/23, Resident #84's medication orders were entered into the computer, when it was discovered by the DON, that he did not have any medications ordered upon his admission to the facility. Resident #84's medications were delivered by the facility's contracted pharmacy later that same day. Resident #84 began receiving his scheduled medications the morning of 07/30/23, after the medication errors were noted, and all were resumed the afternoon of 07/30/23. Resident #84 did not show any adverse effects of not receiving his ordered medication until 07/30/23 at 9:42 A.M., when he was given Ibuprofen as ordered prn for mild pain. • On 07/31/23, LPN #67 received a written warning for failing to enter Resident #84's medications into the computer upon his admission to the facility. She was informed it was expected that all orders would be entered into PCC upon a resident's admission to ensure the timely deliver of the medication from the pharmacy. LPN #67 no longer worked at the facility for an unrelated reason. • On 07/31/23, the facility's DON completed a whole house audit of recent admissions to identify any other residents that could have been affected by the deficient practice. No other issues were noted. • On 07/31/23, the facility's DON provided education to the facility's nurses either in person or via phone regarding the need to enter medications into PCC and ordered from the pharmacy, upon a resident's admission. If they noticed that a resident was not on their MAR, they were to investigate the matter and report accordingly. Failure to initiate/ verify orders upon a resident's admission was a delay of treatment and a medication error that could possibly lead to harm. admission orders must be checked by two nurses on duty upon a resident's admission; 18 nurses received that education. • Ongoing weekly audits were initiated on 08/07/23 and continued to be completed with no issues noted of medications not being ordered for residents upon their admission. Findings of those audits were being reviewed in the facility's weekly Ad hoc QAPI meetings. This deficiency represents non-compliance investigated under Complaint Number OH00145193. 365474 Page 7 of 7