Health inspection·September 13, 2018

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** Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure residents advanced directive wishes were accurate and placed in the residents charts. This affected two resident (#61 and #70) of 24 residents reviewed for advanced directives. The facility census was 88. Findings include: 1. Medical record review revealed Resident #61 admitted to the facility on [DATE]. Diagnoses included right lower leg fracture, hypothyroidism, and chronic kidney disease. Further review revealed the resident's advanced directive wishes, on admission, was to be a Do Not Resuscitate Comfort Care Arrest (DNR-CCA) which meant staff were to continue to provide full treatment up until time the resident went into cardiac arrest. Review of an initial family conference meeting, dated [DATE], revealed Resident #61 changed his/her advanced directive wishes and the resident's wishes were now to be a full code. Full code meant the resident wished to have cardiopulmonary resuscitation (CPR) performed if he/she went into cardiac arrest. Review of the resident's electronic health record revealed the residents advanced directive whishes were DNR-CCA. Interview on [DATE], at 10:12 A.M., the Director of Nursing (DON) revealed all resident's advanced directive wishes were to be placed in the resident's chart on admission. The DON further revealed residents' advanced directive wishes were reviewed at each care meeting to ensure their wishes would be honored. Any changes made were supposed to be updated in both the residents electronic health record and paper chart. The DON verified Resident #61 changed his/her advanced directive wishes on [DATE] during a care meeting and decided he/she wanted to be a full code and wanted CPR to be performed if he/she suffered cardiac arrest. The DON verified an order for the resident's wishes was not obtained and the resident's updated advanced directive's were not updated in the residents electronic health record. The DON further verified the resident's advanced directive wishes in his/her electronic health record were DNR-CCA. 2. Review of the medical record for Resident #70 revealed the resident admitted to the facility on [DATE]. Diagnosis included diabetes mellitus type two, chronic kidney disease, and hypertension. Review of the resident's electronic health record revealed the residents advanced directive whishes were DNR-CCA. Further review of the paper chart for the resident revealed the residents advanced Page 1 of 11 365508 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0578 directive wishes were to be a full code. Level of Harm - Minimal harm or potential for actual harm Review of a physician order, dated [DATE], revealed the resident's advanced directive wishes were changed from a full code to DNR-CCA. Residents Affected - Few Interview on [DATE], at 10:12 A.M., the DON verified the advanced directive wishes for Resident #71 was documented in the electronic health record as DNR-CCA and the resident's paper chart as a full code. The DON further verified the resident changed his/her advanced directive wishes to DNR-CCA on [DATE] and those wishes were never updated in the residents paper chart. Review of a facility policy titled, Code Status & Advanced Directives, dated [DATE], revealed the facility would interview each resident, upon admission, to determine the resident's advanced directive wishes. During the initial Care Conference meeting and quarterly, staff were to review the advanced directive wishes with the resident and/or the resident's family and any updates and/or charges were to be made and communicated to the physician. 365508 Page 2 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on meal observations and staff interviews, the facility failed to ensure resident's had a homelike dining environment. This affected six (Residents #11, #12, #40, #58, #71 and #75) of 88 residents, who ate in the dinning room located near the 200 hallway. Findings include: Observation of the dining services in the small dining room, located just off the 200 hallway was conducted on 09/10/18 at 11:57 A.M. ; 09/11/18 at 8:22 A.M. and 09/11/18 at 5:35 P.M. The staff were observed to provide each of the residents their meals on a large plastic serving tray. The staff left each of the residents meals on the plastic trays. The tables in the area were observed without any homelike décor. Observation of the facility's main dinning room was additionally conducted following each of the above listed 200 hall meals. The residents in the main dining room were provided table cloths, center pieces, salt and pepper shakers and condiment containers, on each of the tables. The residents meals were not served on plastic trays. Interview with the facility Director of Nursing (DON) and Administrator occurred on 09/12/18 at 8:02 A.M. The interview confirmed the staff have never been educated to remove food from the plastic trays for the residents. The interview further identified they have never thought about this dining being different from the main dining location. 365508 Page 3 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

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** 2. Review of Resident #3's medical record identified admission to the facility occurred on [DATE]. Diagnoses included Parkinson's disease and vascular dementia. Resident #3's record identified a wandering/elopement assessment, dated [DATE], identified he was at a high risk for elopement. The written plan of care identified a SCAT ankle alarm would be implemented. The record identified nursing staff were to check and record placement to the alarm daily. 3. Review of Resident #48's medical record identified admission to the facility occurred on [DATE]. Diagnoses included Alzheimer's disease, confusion and agitation. The record identified Resident #48 was high risk for wandering/elopement, upon admission. The plan of care included the use of a SCAT alarm to the residents ankle. Review of the physician notes dated [DATE] identified Resident #48 does try to exit the facility at times but was easy to re-direct. The record included a physician order for the nursing staff to check placement of the SCAT alarm on a daily basis. Observation of Resident #48 occurred on [DATE] at 8:27 A.M. with a SCAT alarm on her left ankle. Review of the maintenance testing logs and interview with Maintenance Assistant #10 was conducted on [DATE] at 12:58 P.M. The interview identified he conducted weekly functional testing of all residents SCAT alarms. Review of the testing logs confirmed each SCAT alarm was individually listed on a testing form and this was completed weekly. Interview with the Administrator and Director of Nursing on [DATE] at 12:58 P.M. confirmed the facility was not doing daily testing of the secure care bands as per the manufacturer's instructions. Review of the SCAT transmitter user guide, dated [DATE] was completed. The transmitter book identified secure care's system must be installed, maintained and tested in accordance with all manuals and instructions in the user guide. The guide additionally identified any person completing the testing must complete technical training. The transmitter policy identified secure Care Products require facilities to test the transmitter for proper operation on a daily basis. The user guide additionally identified the date of the ankle transmitter expiration should be noted so the ankle transmitter was replaced at the proper time, ensuring protection of the resident. Based on medical record review, observation, staff interview, and review of manufacture recommendations, the facility failed to ensure Secure Care Ankle Tracking (SCAT) devices were tested for proper functioning in accordance with the manufacture's instructions. The facility further failed to ensure expired SCAT devices were replaced timely. This affected three (#3, #30 and #48) of three residents reviewed for SCAT devices. The facility identified 12 residents utilizing SCAT devices. The facility census was 88. Findings include: 1. Medical record review revealed Resident #30 admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two, chronic kidney disease, bipolar disorder, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated [DATE], revealed the resident was cognitively intact. 365508 Page 4 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a physician's order, dated [DATE], revealed a SCAT was applied to the residents left ankle and placement was to be check every shift. Review of Resident's Medication Administration Record (MAR) for 08/2018 and 09/2018, revealed the SCAT to the residents left ankle was monitored each shift for placement. No documentation to monitor a SCAT placed on the resident wheelchair was found. Review of a facility log titled, Daily Transmitter Testing Log, revealed the SCAT placed on Resident #30's left ankle was tested on ce a weekly, not daily, for proper functioning. The facility was unable to provide documentation the SCAT applied to the resident's wheelchair was tested for proper functioning. Observation on [DATE] at 10:48 A.M., revealed a SCAT on Resident #30's left ankle. A SCAT was also observed on the bottom of the resident's wheelchair. The SCAT observed on the bottom of the wheelchair had an expiration date of 11/2016. Interview on [DATE] at 1:11 P.M. with Licensed Practical Nurse (LPN) #55 revealed she routinely cared for Resident #30. LPN #55 revealed she was not aware Resident #30 had a SCAT placed on his/her wheelchair Interview on [DATE] at 11:12 A.M. with the Director of Nursing (DON) verified Resident #30 was ordered a SCAT to be worn on his/her left ankle and a second SCAT was placed on Resident #30's wheelchair per nursing judgement. The DON revealed SCAT placement was supposed to be monitored every shift and documented on the resident's MAR. The DON verified there was no documentation the SCAT placed on the resident's wheelchair was monitored each shift. The DON further revealed proper functioning of resident's SCAT were being checked weekly, not daily. The DON further revealed, because there was no documentation on the resident's MAR of the SCAT placed on his/her wheelchair, this SCAT was not being monitored at all for proper functioning. The DON further verified the SCAT located on the resident's wheelchair expired in 11/2016. 365508 Page 5 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 of facility policy and staff interviews, the facility failed to ensure two residents (Resident #146 and #147) were receiving proper care of peripherally inserted central catheter [PICC) access (IV) sites. The facility identified two residents (#146 and #147) who have PICC sites. The facility census was 88. Residents Affected - Few Findings include: 1. Review of Resident #146's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure, CVA (stoke) with right side, seizure disorder, DM, CAD, Depression, HTN (high blood pressure), COPD and Pulmonary Fibrosis. The record identified Resident #146 had a PICC line for intravenous access. The medical record identified a lack of admission physician orders for dressing and/or cap changes for the PICC line. Observation of Resident #146 on 09/11/18 at 7:27 A.M. revealed the resident was observed with a PICC line in the right antecubital area with a dressing dated 08/28/18. Observation and interview with Licensed Practical Nurse (LPN) #55 occurred on 09/11/18 at 10:57 A.M. confirmed the dressing was dated 08/28/18 and had not been changed since Resident #146's admission. 2. Review of Resident #147's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included diabetic foot ulcer and cellulitis. The record further identified physician orders for an antibiotic to be administered through a PICC line. The record lacked any physician orders for dressing and/or cap changes for the PICC line. Observation of Resident #147 with LPN #78 on 09/11/18 at 9:25 A.M. revealed Resident #147 had a PICC Line in the right antecubital with dressing intact. The dressing was noted to be dated 09/05/18. Interview with LPN #147 confirmed the facility did not have any physician orders for the dressing changes and/or cap changes for the PICC line. Review of the facilities undated, PICC line Care policy, identified PICC line dressing change ordered weekly with extension set and cap change. The policy identified each dressing shall be initialed and dated as well as documented in the electronic medical record. 365508 Page 6 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, review of facility policy and staff interview, the facility failed to follow a physician order for oxygen therapy. This affected one (Resident #58) of one resident reviewed for oxygen therapy. The facility identified seven residents receiving oxygen. The facility census was 88. Residents Affected - Few Findings Include: Medical record review for Resident #58 revealed an admission date of 05/01/15. Diagnoses included atherosclerotic heart disease without angina pectoris, adult failure to thrive, dementia without behavioral disturbances, Alzheimer's disease with late onset. Review of physician order, dated 10/27/17, revealed an order for oxygen two liters per minute via nasal cannula indefinitely. Observation on 09/10/18 at 4:00 P.M., 09/11/18 10:48 A.M. and 09/11/18 at 5:35 P.M. revealed oxygen setting between three liters per minute to 3.5 liters per minute via nasal cannula. Interview on 09/11/18 at 5:35 P.M. with License Practical Nurse (LPN # 73 ) confirmed the oxygen was set at three liters per minute. The LPN verified the physician order was for two liters. Review of an undated facility policy titled Policy and Procedure: Oxygen Delivery, revealed oxygen will be used according to physician orders and monitored by nursing. 365508 Page 7 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review manufacture instructions, and staff interview, the facility failed to properly administer insulin via a FlexPen injector. This affected one resident (#94) of one resident, observed for insulin administration via a FlexPen, and had the potential to affect five resident's (#37, #55, #66, #68, and #94) who were identified by the facility to receive insulin via a FlexPen on the two west hall. The facility census was 88. Findings include: Medical record review revealed Resident #94 admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two and vascular dementia without behavioral disturbances. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/21/18, revealed the resident's cognition was intact. Review of Resident #94's physician orders revealed an order, dated 11/07/17, for 10 units of Novolog, via a FlexPen injector, to be administered subcutaneously with each meal. Observation of medication administration on 09/12/18 at 4:27 P.M., revealed Licensed Practical Nurse (LPN) #104 went to the medication storage room and obtained a new Novolog FlexPen for Resident #94. LPN #104 placed a needle onto the FlexPen injector and set the pen at 10 units. LPN #104 proceeded to the resident's room and administered the insulin to Resident #94. Interview on 09/12/18 at 4:28 P.M., LPN #104 revealed she was not sure if a Novolog FlexPen injector required to be primed (a process to remove the air from the needle and cartridge of the injector to ensure the proper dose of insulin is administered) prior to obtaining the residents 10 units of insulin. LPN #104 verified she did not prime the Novolog FlexPen injector prior to administrating Resident #94's insulin. Interview on 09/13/18 at 8:35 A.M., the Director of Nursing (DON) revealed Novolog FlexPen injectors were required to be primed, prior to obtaining the ordered dose of insulin, to ensure the proper dose of insulin was obtained. Review of the manufacture's instructions titled, A Guide to Using Your Novolog FlexPen, that was provided with the resident's new Novolog FlexPen injector, revealed to prime the Novolog FlexPen injector, the cap was to be removed and a new needle was to be attach to the injector. The dose selector was to be set at two units, and with the needle in the up position, the injection button was to be pressed and held to expel the two units (until a drop of insulin could be seen on the tip of the needle). Next, the ordered dose of insulin was to be set on the dose selector for administration. 365508 Page 8 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

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 medical record review and staff interviews, the facility failed to ensure Resident #48 was not receiving unnecessary anti-psychotropic mediations. This affected one (#48) of five residents reviewed for unnecessary medications. The facility identified 17 residents receiving anti-psychotropic medications. The facility census was 88. Findings include: Review of Resident #48's medical record identified an admission occurred on 10/22/17. Diagnoses included Alzheimer's disease, anxiety, depression and dementia. Review of the admission physician orders included an anti-psychotropic medication (Seroquel) 50 milligrams (mg.) daily. The Seroquel was discontinued on 11/14/17. On 11/20/17, the Seroquel medication was re-started, for an unknown reason. Review of the nursing progress notes and physician progress notes from 10/22/17 through 11/20/17, revealed lack of any evidence of indications for the Seroquel to be restarted. The medical record did identify on 11/24/17 Resident #48 was identified with a urinary tract infection and required antibiotic therapy. The record lacked any evidence of identifying the infection could potentially be the cause of any behavioral changes for Resident #48. Review of the physician's admission History and Physical for Resident #48 identified the [AGE] year old admitted from another nursing facility on 10/22/17 with increased confusion, agitation and lethargy. The physical evaluation identified Resident #48 was checked for and identified with a urinary tract infection. The plan identified he would hold off weaning her atypical anti-psychotic (Seroquel) until we have more information. Review of Resident #48's care conference meeting, occurring with family was dated 10/31/17. The meeting identified a discussion of the Seroquel was completed. The notes identified the family revealed the Seroquel was originally started Thanksgiving 2016 for an acute psychotic episode (short duration). Review of physician progress notes ,dated 11/09/17, identified Resident #48 was assessed with no dementia behaviors at this time, she does try at times to leave but was easy to re-direct and seem well adjusted. Pleasant and gets along with roommate. The notes, dated 12/05/17 identified Resident #48 was clinically stable. The patient has had no episodes of acute psychosis. On 02/01/18, Resident #48's pharmacy recommended a gradual dose reduction of the Seroquel medication down to 25 mg. daily. The medical record identified the reduction was completed without issues for Resident #48. The Medication Administration record (MAR) dated September 2018 identified Resident #48 remained on the Seroquel medication 25 mg. daily. Review of the behavior progress notes dated 02/02/2018 at 12:22 P.M. identified Resident #48 has been pleasant and cooperative with care and in interactions with others. No concerning behaviors noted. The plan was to decrease the Seroquel to 25 mg. every day. 365508 Page 9 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0758 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 09/11/18 at 2:04 P.M. confirmed she was unable to locate and indications for use of Seroquel for Resident #48. The interview further confirmed Resident #48 does have some increased anxiety and possible behaviors, when she has a urinary tract infection. The interview further confirmed Resident #48 has not demonstrated any behaviors that would warrant the use of a anti-psychotic medication since admission. Residents Affected - Few Interview with State Tested Nursing Assistant (STNA) #125 on 09/12/18 at 9:05 A.M. confirmed STNA #125 has taken care of Resident #48 since her admission to the facility. The STNA confirmed Resident #48 has never had any behaviors, and was always pleasant. The interview confirmed when Resident #48 has a urinary tract infection she does sleep a lot and was grouchy, but this goes away following treatment. 365508 Page 10 of 11 365508 09/13/2018 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

F 0880 Provide and implement an infection prevention and control program. 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, review of manufacture instructions, and staff interview, the facility failed to properly disinfect a community glucometer (a blood glucose monitoring device), after obtaining a resident's blood glucose level. This affected one resident (#94) of two residents observed for blood glucose monitoring and had the potential to affect eight residents (#5, #22, #29, #37, #65, #66, #68, and #94) who were identified by the facility to have orders for blood glucose monitoring on the two west hall. The facility census was 88. Residents Affected - Some Findings include: Medical record review revealed Resident #94 admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two, hyperlipidemia, and vascular dementia without behavioral disturbances. Review of the comprehensive Minimum Data Sets (MDS) assessment, dated 08/21/18, revealed the resident's cognition was intact. Review of Resident #94's physician orders revealed an order, dated 11/03/17, for the resident's blood glucose level to be monitored three times a day with each meal. Observation on 09/12/18 at 4:16 P.M., revealed Licensed Practical Nurse (LPN) #104 used a glucometer to obtained Resident #94's blood glucose level. LPN #104 then proceeded to the medication cart and wiped the glucometer using a germicidal disposable wipe. LPN #104 was observed wiping the glucometer with a germicidal wipe for approximately 30 seconds. Interview on 09/12/18 at 4:28 P.M., LPN #104 verified the glucometer was a community glucometer and used for all of the residents on the two west hall who required blood sugar monitoring. LPN #104 revealed the glucometer was supposed to be cleaned, with a germicidal wipe, after each use for at least 30 seconds. LPN #104 verified she used a germicidal wipe and cleaned the glucometer for 30 seconds. Interview on 09/13/18 at 8:35 A.M., the Director of Nursing verified community glucometers were to be wiped thoroughly with a germicidal wipe, for at least two minutes, after each use to disinfect the glucometer. Review of the manufacture's instructions provided with the germicidal wipe, revealed after use, staff were to thoroughly wipe the surface of the glucometer, with a germicidal wipe, for two minutes to disinfect and kill blood born pathogens including viral hepatitis and human immunodeficiency virus (HIV). 365508 Page 11 of 11