Health inspection·November 6, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to treat a resident with respect and dignity while providing care. This affected one resident (#37) of four residents observed for medication administration. The facility census was 85. Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included Down Syndrome, early onset Alzheimer's disease and profound intellectual disabilities. Review of the resident's quarterly Minimum Data Set assessment, dated 08/28/19, revealed the resident's cognition was severely impaired. Review of the resident's most recent care plan, revised 09/06/19, revealed Resident #37 had a communication deficit related to impaired cognition and did not speak. Interventions included to talk with the resident while providing care and converse about current events and to explain to the resident the care you were going to perform, prior to performing it, Observation on 11/04/19 from 7:30 A.M. through 8:05 A.M. revealed Licensed Practical Nurse (LPN) #275 gathered the resident's tube feeding and prepared Resident #37's medication to be administered through the resident's gastric tube. LPN #275 entered the resident's room, pulled her blanket down to expose her gastric tube and began administering medication through the tube one at a time. After administering the medication LPN #275 administered the tube feeding into the gastric tube. When the LPN was finished, he prepared a breathing treatment for the resident. LPN #275 grabbed and removed her oxygen mask from her face and replaced it with the mask for the breathing treatment and started the treatment. LPN #275 covered the resident back up and left the room. At no time was LPN #275 observed to speak to the resident nor did he make any attempts to explain what he was going to do with her before he did. Interview on 11/04/19 at 8:06 A.M., LPN #275 confirmed he did not speak to Resident #37 at no point while in the resident's room and confirmed he should have spoken to her and let her know what he was going to do. Review of a facility policy titled, Medication Administration; Enteral Tube Medication Administration dated 06/21/19, revealed staff were to explain the procedure and medication to the resident, prior to administering. Page 1 of 4 365508 365508 11/06/2019 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

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, staff interview, and review of the Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessments was accurate. This affected one resident (#37) of 18 residents reviewed for accuracy of assessments. The facility census was 85. Residents Affected - Few Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included Sown syndrome, early on-set Alzheimer's disease and chronic obstructive pulmonary disease. Further review revealed the resident received Hospice services since 05/24/19. Review of the resident's significant change MDS assessment dated [DATE], section O0100K, asked if the resident was receiving Hospice services. The MDS was coded no which indicated the resident was not receiving Hospice services. Review of her quarterly MDS assessment dated [DATE], section O0100K, asked if the resident was receiving Hospice services and again the MDS was coded no which indicated the resident was not receiving Hospice services. Interview on 11/05/19 at 3:04 P.M., Registered Nurse (RN) #279 revealed she was the facility MDS Coordinator. RN #279 confirmed Resident #37 was receiving Hospice services since 05/24/19 and was receiving these services at the time her significant change MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] were completed. RN #279 further confirmed Resident #37's significant change and quarterly MDS assessments were coded incorrectly and did not reflect the resident's hospice status. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version, 1.17.1, chapter three, page 0-5, dated 10/2019, revealed the facility should code yes to question O0100K for residents identified as being in a hospice program for terminally ill persons where an array of services were provided for the management of terminal illness. 365508 Page 2 of 4 365508 11/06/2019 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

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 and staff interview, the facility failed to ensure medications were administered according to ordered parameters. This affected two residents (#70 and #60) of four residents reviewed for medications. The facility census was 85. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #70 admitted to the facility on [DATE]. Diagnoses included hypertension, hypotension and chronic atrial fibrillation. Review of Resident #73's physician orders revealed the resident was ordered Metoprolol Tartrate (medication to treat high blood pressure) 25 milligrams (mg), give 0.5 tablet to equal 12.5 mg two times a day (upon rising and at bedtime). Further review of the order revealed staff were supposed to hold the medication for a systolic blood pressure less than 120 millimeters of mercury (mm Hg). Review of the resident's Medication Administration Record (MAR) revealed on 10/16/19, 10/18/19, 10/21/19, 10/22/19, 10/23/19, 10/26/19, 10/27/19, 10/31/19, 11/01/19 and 11/04/19 the resident received her upon rising dose of Metoprolol Tartrate and her bedtime dose on 10/19/19, 10/27/19 and 10/30/19. Further review of the MAR revealed the resident's documented blood pressure reading was less than 120 mm Hg with each administration. Interview on 11/05/19 at 2:41 P.M., the Director of Nursing (DON) confirmed Resident #73 received her dose of Metoprolol Tartrate on the above listed dates and times despite documentation the resident's systolic blood pressure reading was less than 120 mm Hg. The DON confirmed the resident's medication should not have been administered. 2. Medical record review Revealed Resident #60 admitted to the facility on [DATE]. Diagnoses included hypertension, hyperlipidemia and asthma. Review of Resident #60's physician orders revealed the resident was ordered Metoprolol Tartrate 50 mg, give 0.5 tablet one time a day. Further review of the order revealed staff were supposed to hold the medication for a systolic blood pressure less than 100 mm Hg. Review of the resident's MAR revealed on 10/04/19, 10/05/19 and 11/03/19 the resident's documented blood pressure was less than 100 mm Hg however, the medication was administered. Interview on 11/05/19 at 2:42 P.M., the DON confirmed Resident #60 received her dose of Metoprolol Tartrate on the above listed dates despite documentation the resident's systolic blood pressure reading was less than 100 mm Hg. The DON confirmed the resident's medication should not have been administered. 365508 Page 3 of 4 365508 11/06/2019 Welcome Nursing Home 417 South Main Street Oberlin, OH 44074

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 medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents received medications as ordered. Observations of 31 medications being administered to four residents with two errors resulted in a medication error rate of 6.4%. This affected on resident (#37) of four residents observed for medication administration. The facility census was 85. Residents Affected - Few Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included seizure disorder, Down Syndrome, early onset Alzheimer's disease and profound intellectual disabilities. Review of the resident's quarterly Minimum Data Set assessment, dated 08/28/19, revealed the resident's cognition was severely impaired. Review of Resident #37's physician orders revealed the resident was to receive 188 milliliters (ml) of Isosource 1.5 enteral feeding, four times a day. Further review revealed the resident was ordered Keppra solution 500 milligrams (mg) per 5 ml, give 1000 mg two times a day. Observation on 11/04/19 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #275 obtained a bottle of Keppra (anti-epileptic drug) 500 mg per 5 ml, and poured 5 ml into a medicine cup and gave the medication via the gastric tube. The LPN verified there was 5 ml of Keppra in the cup he administered to the resident. He then opened the carton of Isosource 1.5 enteral feeding and poured it into a measuring cup. The measuring cup measured 100 ml, 200 ml and 300 ml. LPN #275 filled the measuring cup between 100 ml and below 200 ml. LPN #275 then administered the Isosource 1.5 enteral feeding from the measuring cup through the syringe into the resident's gastric tube. Interview on 11/04/19 at 8:06 A.M., with LPN #275 confirmed he administered 500 mg of Keppra to Resident #37 instead of the ordered 1000 mg. LPN #275 further confirmed he did not know the exact amount of Isosource 1.5 enteral feeding he had administered to the resident because he didn't have a measuring device to ensure the resident received the ordered 188 ml of Isosource. Review of a facility policy titled, Medication Administration; Enteral Tube Medication Administration dated 06/21/19, revealed it was the facility policy to safely and accurately administer medications through an enteral feeding tube. Staff were supposed to check the Medication Administration Record for the order, read the medication label three times before administering comparing with the MAR. 365508 Page 4 of 4