Health inspection·August 28, 2019

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 and staff interview, the facility failed to timely transmit a quarterly Minimum Data Set (MDS) assessment to The Centers for Medicare and Medicaid Services (CMS). This affected one (#1) of 22 residents reviewed during the investigation stage of the survey. The census was 64. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 03/14/17. Diagnoses included unspecified fracture of upper end of unspecified tibia, secondary Parkinsonism, and dysphagia. Review of Resident #1's MDS assessments revealed the most recently completed annual MDS assessment was completed and transmitted on 01/11/19. Resident #1 had quarterly MDS assessments completed on 04/08/19 and 07/01/19, however, the quarterly MDS assessment completed on 07/01/19 was not transmitted to CMS. During review of Resident #1's MDS assessments, the quarterly MDS assessment dated [DATE] was marked as completed, however not locked, or transmitted to CMS as of 08/28/19 at 9:00 A.M. Interview on 08/28/19 at approximately 2:30 P.M., with MDS Nurse #110 verified Resident #1's quarterly MDS assessment completed on 07/01/19 was not timely transmitted to CMS. Page 1 of 8 365489 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

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 and staff interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate. This affected one resident (#17) of 19 reviewed during the annual survey. The facility census was 64. Residents Affected - Some Findings include: Medical record review revealed Resident #17 admitted to the facility on [DATE]. Diagnoses included fracture of the first lumbar vertebra, fracture with delayed healing and low back pain. Review of the resident's physician orders revealed an order dated 11/13/18 to administer Tramadol (opioid pain medication) 50 milligrams (mg) two tablets every six hours as needed for pain. Review of the resident's Medication Administration Record (MAR) for 03/2019 revealed the resident was administered two Tramadol 50 mg tablets on 03/27/19 at 4:22 A.M., 03/28/19 at 12:03 P.M. and 03/31/19 at 3:39 P.M. Review of the resident's comprehensive MDS assessment, dated 04/02/19, section N0300 H, revealed the resident did not receive an opioid pain medication during the seven day look back period (03/27/19 through 04/02/19). Further review of the resident's 07/2019 MAR revealed the resident was administered the Tramadol on 07/01/19 at 2:15 P.M., 07/02/19 at 2:20 P.M. and 07/03/19 at 11:28 A.M. Review of the resident's quarterly MDS assessment, dated 07/07/19, section N0300 H, also revealed the resident did not receive an opioid pain medication during the seven day look back period (07/01/19 through 07/07/19). Interview on 08/26/19 at 3:30 P.M., with Registered Nurse (RN) #110 revealed she completed Resident #17's comprehensive MDS assessment dated [DATE] and quarterly assessment dated [DATE]. RN #110 confirmed the resident received Tramadol, on the above stated dates, during the look back period of both assessments. RN #110 further confirmed section N0300 H of both assessments did not reflect the resident received an opioid medication. RN #110 revealed she did no know Tramadol was an opioid medication. 365489 Page 2 of 8 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. Review of Resident #19 medical record revealed an admission date of 04/19/17. Diagnoses included major depression, ataxia, muscle weakness, muscle wasting and atrophy, and unsteadiness on feet. Review of a physician order dated 10/31/18 revealed Resident #19 was ordered a mat to the floor to prevent injury. Review of a fall care plan dated 02/18/19 revealed Resident #19 was at risk for falls with an intervention to have a floor mat to the right side of the bed when Resident #19 was in bed. Review of the most recently completed MDS assessment dated [DATE] revealed Resident #19 was cognitively intact, required and extensive assistance with bed mobility and transfers, and had no falls since admission or since the prior assessment completed on 04/17/19. Review of the most recently completed fall risk assessment completed 07/09/19 revealed Resident #19 was a high risk for falling. Observation on 08/25/19 at 2:14 P.M. revealed Resident #19 was laying in bed with his bed in the low position with no mat to the floor on either side of the bed. Observation on 08/27/19 at 8:03 A.M. revealed Resident #19 laying in bed free from distress with no mat to the floor on either side of the bed. Further observation revealed a mat folded in the corner of the room placed between a night stand and the wall. Interview on 08/27/19 at 8:14 A.M. with LPN #120 verified Resident #19 had an order to have a floor mat when he was in bed. LPN #10 confirmed Resident #19 was in bed with no floor mat in place. Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident safety while smoking. This affected three residents (#20, #24, and #48) of four residents reviewed for smoking. In addition, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one resident (#19) of three reviewed for falls. The facility census was 64. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 08/28/17. Diagnosis included diabetes mellitus type 2, hemiplegia, and atherosclerotic heart disease. Resident was noted to be cognitively intact. Interview on 08/25/19 at 2:34 P.M. with Resident #20 revealed the resident maintains cigarettes and lighter in his/her personal possession. Review of Resident #20's annual Smoking Safety Screen dated 07/31/19 revealed staff were to keep the resident's cigarettes and lighter. Observation on 08/26/19 at 3:12 P.M. revealed Resident #20 had cigarettes and lighter with him/her 365489 Page 3 of 8 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

F 0689 and was not being supervised. Level of Harm - Minimal harm or potential for actual harm Interview on 08/27/19 at 10:01 A.M. with State Tested Nursing Aid (STNA) #117 verified Resident #20 maintains personal possession of his/her cigarettes and lighter. Residents Affected - Some Interview on 08/27/19 at 2:10 P.M. with Licensed Practical Nurse (LPN) #118 verified Resident #20 maintains personal possession of his/her cigarettes and lighter. 2. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes mellitus type 2, and muscular dystrophy. The resident was noted to be cognitively intact. Review of Resident #24's annual Smoking Safety Screen dated 07/31/19 revealed the safety modifications revealed staff were to keep the resident's cigarettes and lighter. Interview on 08/25/19 at 3:05 P.M. with Resident #24 confirmed the resident had personal possession of cigarettes and lighter. Observation on 08/26/19 at 9:51 A.M. revealed Resident #24 was in the designated courtyard unsupervised. Resident #24 obtained cigarettes and lighter from his/her personal bag and smoked unsupervised. Interview on 08/27/19 at 10:06 A.M. with STNA #117 verified Resident #24 maintained personal possession of his/her cigarettes and lighter. Interview on 08/27/19 at 2:14 P.M. with LPN #118 verified Resident #24 maintains personal possession of his/her cigarettes and lighter. 3. Review of Resident #48's medical record revealed an admission date of 04/29/13 with diagnoses including congestive heart failure, pulmonary edema,and end stage renal disease. The resident required oxygen and was cognitively intact. Review of Resident #48's annual Smoking Safety Screen dated 07/31/19 revealed the resident was safe to smoke independently in designated smoking areas. Interventions included staff to retain cigarettes, staff to retain lighter and supervised smoking times. Review of Resident #48's most recent care plan revealed the resident was to be reviewed for smoking safety quarterly. Staff was to retain cigarettes and lighter. The resident was to wear a non-flammable apron or cover/barrier during smoking activity. Resident #48 had oxygen therapy related to ineffective gas exchange. Observations of Resident #48 on 08/27/19 at 8:44 A.M. and 2:13 P.M. revealed the resident was in the facility front parking lot smoking by him/herself. Interview with LPN #120 on 08/27/19 at 5:10 P.M. verified that Resident #48 was outside in the front parking lot unsupervised and smoking. In addition, LPN #120 verified Resident #48 kept his/her cigarettes and lighter on his/her own person or in his/her room. Interview with MDS/Care Plan nurse #110 on 08/28/19 at 9:12 A.M. revealed the resident was care 365489 Page 4 of 8 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

F 0689 planned to keep the cigarettes and lighter in a smoking materials secured container at the nurses station. Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled Facility Smoking Rules revealed staff members, residents, and visitors shall be permitted to smoke only in designated areas. The designated smoking area for this facility is located in the court yard and in the front sidewalk. Residents Affected - Some 365489 Page 5 of 8 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of a facility policy, the facility failed to ensure pharmacy recommendations were addressed timely. This affected two residents (#33 and #28) of six reviewed for unnecessary medications. The facility census was 64. Findings include: 1. Medical record review revealed Resident #33 admitted to the facility on [DATE]. Diagnoses included major depressive disorder and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 07/22/19, revealed the resident had impaired cognition. Review of the resident's physician orders revealed the resident was prescribed Buspirone 10 milligrams (mg) every morning and at bedtime for anxiety. Review of the resident's monthly pharmacy review report, dated 03/22/19, revealed it was a repeated recommendation for the physician to consider a gradual dose reduction from 10 mg twice a day to 7.5 mg twice a day. The date of the original recommendation request was 01/27/19 and the facility was asked to please respond promptly to assure facility compliance with Federal regulations. The recommendation was not addressed by a physician until 04/24/19. Interview on 08/27/19 at 4:44 P.M., the Director of Nursing (DON) confirmed the resident's 03/22/19 monthly pharmacy review was a repeated request from 01/27/19 for the physician to consider a gradual dose reduction for Resident #33's Buspirone medication. The DON further confirmed there was no evidence the physician addressed the pharmacy's request until 04/24/19, the date the physician signed the form. 2. Review of Resident #28's medical record revealed an admission date of 04/18/11. Diagnoses included unspecified dementia without behavioral disturbances, major depression, anxiety, hyperlipidemia, essential hypertension. Review of a pharmacy consultation report dated 09/19/18 revealed Resident #28 had not used her as needed narcotic pain medication Tramadol in the past 60 days. The pharmacist recommended the medication be discontinued due to lack of use. Further review of the pharmacy consultation report revealed the facility never responded to the pharmacy recommendation, and Resident #28's as needed Tramadol order remained unchanged from the original order dated of 05/02/18. Review of a monthly pharmacy review progress noted completed on 02/23/19 revealed Resident #28 had an irregularity in her medication regimen identified, however, the facility was not able to provide the pharmacy recommendation document from the medication review on 02/23/19. Review of a consultation report dated 05/22/19 revealed a pharmacy recommendation, with a notation of a repeated recommendation from 02/23/19, to address Resident #28's as needed analgesic Biofreeze 4% gel that did not specify the frequency of use. The facility responded to the recommendation on 05/24/19. Interview on 08/28/19 at 1:03 P.M. with the DON #106 verified Resident #28's pharmacy recommendations from 09/19/18 and 02/23/19 were not responded to in a timely manner. DON #106 verified the facility did not have any documentation of Resident #28's pharmacy recommendation from 02/23/19. 365489 Page 6 of 8 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a facility policy titled, Psychotropic Medication Use, most recent revision date 11/28/16, revealed the facility was supposed to comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services, the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions. Psychopharmacologic medications were any medication that affected brain activity associated with mental processes and behavior. Further review revealed all medications used to treat behaviors were supposed to have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. 365489 Page 7 of 8 365489 08/28/2019 Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, review of hospital records, staff interview, and review of a facility policy, the facility failed to ensure residents did not receive unnecessary medication. This affected one resident (#204) of six reviewed for unnecessary medications. The facility census was 64. Residents Affected - Few Findings include: Medical record review revealed Resident #204 admitted to the facility on [DATE]. Diagnoses included protein-calorie malnutrition, unspecified chronic pain due to trauma, anxiety. Review of the resident's discharge orders, dated 08/19/19, from an acute care hospital revealed the resident was not ordered any antibiotic medications. Review of the resident's 08/19/19 facility admission orders revealed the resident was ordered Zithromax (antibiotic) 250 milligrams (mg) daily for infection. Review of Resident #204's Medication Administration Record (MAR) revealed the resident was administered Zithromax 250 mg daily, in the morning, from 08/20/19 through 08/27/19. Interview on 08/27/19 at 1:44 P.M., with the Director of Nursing (DON) confirmed on 08/19/19 the resident was ordered Zithromax 250 mg to be given daily. The DON further confirmed the resident was administered the medication daily beginning 08/20/19 through 08/27/19, however stated she did not know why the resident was ordered Zithromax. The DON confirmed the resident received the medication unnecessarily. Review of a facility policy titled, New admission Review Best Practice, dated 04/2019, revealed the facility was to ensure each new admission was to have all necessary orders, assessments, and other documentation necessary to provide appropriate care. 365489 Page 8 of 8