Health inspection·January 30, 2020

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Potential for minimal harm Based on review of resident council meetings, staff and resident interview, review of facility policy and Resident [NAME] of Rights, the facility failed to act promptly upon grievances of Resident Council nor demonstrate their response and rationale. This had the potential to affect all 121 residents. Residents Affected - Many Findings include: Review of Resident Council Meeting minutes dated 08/27/19, 09/27/19, and 12/31/19 revealed Resident #81, the Resident Council president, had the following concerns: wanted less rice and fish, the food should have better flavor and he wanted to be asked what kind of snacks he would prefer at night. Further review of Resident Council documentation lacked evidence of facility follow-up, and/or rationale for not implementing recommendation/concerns. Interview on 01/28/20 at 12:32 P.M. with Activity Director (AD) #204 revealed she did not have evidence of follow-up for the concerns expressed on 08/27/19, 09/27/19, or 12/31/19. She stated she was not aware, until the surveyor inquired about follow-up from Resident Council, she was supposed to be completing another form. AD #204 stated she would put concerns on a Grievance Form and give to the social worker if a resident alleged abuse, or, had a big care concern, but she had never done Resident Council follow-up for less serious concerns and /or recommendations from Resident Council. She confirmed she was using copies of a hand-written form to document Resident Council, not the facility's specified form. Interview with Resident #81 on 01/28/20 at 2:04 P.M. revealed the facility did not follow-up on Resident Council concerns, specifically his. He stated staff would just say they were working on the issues but the issues were still not resolved. Review of facility policy titled, Resident Council, undated, revealed the facility supported and assisted residents with establishing and maintaining an effective forum for contributing suggestions for center improvement and addressing areas of concern. Residents may introduce requests or issues during the meeting and that Resident Council Minutes, form is used to document requests. The Administrator and Department heads were responsible for responding to the issues. The response to the request or issue would be read at the next scheduled Resident Council meeting. If the outcome was accepted, the staff facilitator/advisor would indicate such on the form. The Administrator would then sign the form acknowledging review and acceptance. Meeting minutes were maintained in a binder and would reflect residents' satisfaction in addressing specific issues discussed at the prior month's meeting. Resident Council Minutes form with department responses would be attached to the Resident Council Minutes. Page 1 of 16 365514 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0565 Level of Harm - Potential for minimal harm Review of the [NAME] of Resident Rights, undated, revealed the facility must designate a staff person who was responsible for providing response to written requests that result from group meetings. The [NAME] of Rights also revealed the facility must be able to demonstrate their response and rationale for such response. Residents Affected - Many 365514 Page 2 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Potential for minimal harm Based on observation, interview with facility staff and residents, observations, and review of Resident [NAME] of Rights the facility failed to ensure a list of names, addresses, and telephone numbers for pertinent State regulatory and informational advocates were posted. This had the potential to affect all the residents. The census was 121. Residents Affected - Many Findings include: Observation 01/27/20 at 4:30 P.M. revealed no postings of the required contact information for State regulatory as well as informational and advocacy groups. Interview on 01/27/20 at 4:56 P.M. the Administrator confirmed the required contact information was not posted in the facility. He stated he had only worked at the facility for six days and the required postings must have been taken down. Interview during Resident Council Facility Task on 01/28/20 at 2:04 P.M., Resident #81 (the Resident Council president) indicated he was not aware of any postings for contact information for State agencies and/or advocacy groups. Review of the Resident [NAME] of Rights, undated, revealed the facility must post, in a form and manner accessible and understandable to residents, and resident representatives a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. 365514 Page 3 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 nterview, and review of facility guidelines the facility failed to accurately assess residents in the Pre-admission Screening/Resident Review (PASRR) process. This affected two Resident's (#66 and #109) of four residents reviewed for PASRR's. The census was 121. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 11/14/19 with diagnoses including bipolar disorder, depression, and hypertension. Review of Resident #66's PASRR dated 11/14/19 revealed the resident was marked as having a diagnosis of panic or other severe anxiety disorder. Further review of Resident #66's PASRR dated 11/14/19 revealed the residents diagnosis of bipolar disorder was not included on the PASRR. Interview with Social Services Director (SSD) #205 on 01/28/20 at 3:52 P.M. verified Resident #66 had a diagnosis of bipolar disorder and it was not included on the PASRR dated 11/14/19. During the interview, Director of Social Services #205 verified the residents diagnosis of bipolar disorder should have been included on the PASRR dated 11/14/19. 2. Review of Resident #109's medical record revealed an admission date of 02/16/18. Diagnoses included convulsions, schizoaffective disorder, epilepsy, and major depressive disorder. Review of Resident #109's census information revealed she admitted to hospice services on 01/03/20. Review of Resident #109's Significant Change Minimum Data Set (MDS) dated [DATE], revealed she had a moderate cognitive impairment and received hospice services. Further review of Resident #109's medical record revealed a PASRR dated 10/31/19. Resident #109's diagnoses of epilepsy, an intellectual disability (ID) elated condition, was not on the PASRR, inaccurately screening Resident #109 for potential additional services. Interview on 01/28/20 at 3:56 P.M. with SSD #205 confirmed Resident #109 was not accurately screened for potential additional services as her diagnoses of epilepsy, an ID related condition was not included on her PASRR dated 10/31/19. Review of the facility's PASRR Guidelines, undated, indicated the purpose of the PASRR was to ensure that all candidates for admission were eligible as appropriate placements to long term care facilities. 365514 Page 4 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility guidelines, the facility failed to notify the state mental health authority and state intellectual disability (ID) authority after a significant change. This affected one (Resident #109) of four residents screened for Pre-admission Screens/Resident Reviews (PASRR). The census was 121. Findings include: Review of Resident #109's medical record revealed and admission dated of 02/16/18. Diagnoses included convulsions, schizoaffective disorder, epilepsy, and major depressive disorder. Review of Resident #109's census information revealed she admitted to hospice services on 01/03/20. Review of Resident #109's Significant Change Minimum Data Set (MDS) dated [DATE], revealed she had a moderate cognitive impairment and received hospice services. Further review of Resident #109's medical record revealed a PASRR dated 10/31/19. Resident #109's diagnoses of epilepsy, an ID-related condition, was not on the PASRR. The medical record lacked evidence a PASRR was completed following her significant change of admitting to hospice services on 01/03/20. There was no evidence the state mental health authorities or state ID authorities were notified after the residents significant change. Interview on 01/28/20 at 3:56 P.M. with Social Service Director (SSD) #205 confirmed Resident #109 was not accurately screened for potential additional services as her diagnoses of epilepsy, an ID related condition was not included on her PASRR dated 10/31/19. SSD confirmed the appropriate authorities were not notified via the PASRR process that Resident #109 had a significant change and elected hospice services 01/03/20. SSD #205 stated she was not aware residents who had a significant change required updated PASRRs to notify appropriate state authorities. Review of the facility's PASRR Guidelines, undated, indicated the purpose of the PASRR was to ensure that all candidates for admission were eligible as appropriate placements to long term care facilities. 365514 Page 5 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of facility policy the facility failed to address frequent urinary tract infections (UTIs) on the comprehensive care plan. This affected one (Resident #10) of 22 residents reviewed for comprehensive care plans. The census was 121. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/13/16 with diagnoses including hemiplegia/hemiparesis, cerebral infarction, and diabetes mellitus type two. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 was coded as always incontinent of bowel and required extensive staff assistance with toileting. Review of Resident #10's active physician orders revealed an order dated 11/27/19 for Macrobid, an antibiotic, 100 milligram (mg) capsule by mouth once per day due to frequent UTIs. The physician order for Macrobid dated 11/27/19 did not include a stop date. Review of Resident #10's Medication Administration Record (MAR) dated January 2020 revealed staff administered the Macrobid every day as ordered from 01/01/20 through 01/30/20. Review of Resident #10's comprehensive care plan revealed no evidence of the residents frequent UTIs being addressed in the care plan. Interview with Director of Nursing (DON) on 01/30/20 at 9:34 A.M. verified Resident #10's comprehensive care plan did not address the residents frequent UTI's or use of Macrobid. Review of the policy titled Plan of Care Overview, last revised 07/26/18, revealed the purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to their daily routines and goals to potentially return to a community setting. 365514 Page 6 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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. Record review of Resident #72 revealed an admission date of 01/25/19 with pertinent diagnoses of vascular dementia with behavioral disturbance, hemiplegia and hemiparesis following intracerebral hemorrhage affecting right dominant side, generalized anxiety disorder, lupus anticoagulant syndrome, hypothyroidism, hypertension, heart failure, visual hallucinations, tracheostomy status, seizures, major depressive disorder, and dysphagia. Review of the 11/02/19 significant change MDS assessment revealed Resident #72 was rarely understood and required total dependence for bed mobility, transfer, toilet use, personal hygiene, and eating. The resident was always incontinent of bowel and bladder. Review of Resident #72's progress notes dated 09/24/19 revealed only one documented instance of a quarterly care conference being held in the last year Interview with SSD #205 on 01/29/20 at 11:00 A.M. verified Resident #72 only had one care conference in the last year. Based on medical record review, interview and review of facility policy,the facility failed to update the care plan when a resident's fluid restriction was discontinued. This affected one (Resident #94) of one resident reviewed for hydration. The facility also failed to conduct quarterly care conferences for three Residents (#22, #72, and #109) of five residents reviewed for participation in care planning. The census was 121. Findings include 1. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, polydipsia, hypertension, generalized anxiety disorder, and convulsions. Review of the comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #94 was independent in activities of daily living with set up help only. Review of physician orders revealed Resident #94 received a regular diet with regular food texture and thin consistency fluids. A fluid restriction consisting of 2000 cubic centimeters (cc) per 24 hours was ordered on 01/23/19 with fluids to be given as follows: Dietary to provide 420 cc of fluid with breakfast, 480 cc with lunch, 240 cc at 2:00 P.M., and 360 cc with dinner. Nursing to provide 480 cc of fluid from 7:00 A.M. to 3:00 P.M., 160 cc of fluid from 3:00 P.M. to 11:00 P.M., and 160 cc of fluid from 11:00 P.M. to 7:00 A.M. The fluid restriction was discontinued on 01/28/20. Review of the care plan revealed a care area for behavior problems related to socially inappropriate behavior at times, resisting care and medications, and noncompliance with the fluid restriction. Interview with the Director of Nursing (DON) on 01/29/20 at 10:52 A.M. verified the resident was not on a fluid restriction as indicated on the care plan. Review of the facility's policy titled General Hydration Services. revised 04/01/16 revealed it was 365514 Page 7 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility's policy to provide adequate fluids and provide fresh water at the bedside. The care plan would be updated with any changes. 2. Review of Resident #109's medical record revealed she admitted to the facility on [DATE]. Her medical record revealed she had a court-appointed guardian. Diagnoses included chronic obstructive pulmonary disease, type 2 diabetes, schizoaffective disorder, and schizoaffective disorder. Review of Resident #109's significant change Minimum Data Set (MDS), dated [DATE], revealed she had a moderate cognitive impairment. Further review of Resident #109's medical record revealed the last documented care conference was held on 09/04/19. Review of the care conferences note dated 09/04/19 revealed Resident #109's guardian was not in attendance. The medial record lacked evidence of an attempt to reach Resident #109's guardian in regards to the care conference. Phone interview on 01/28/20 at 2:24 P.M. with Resident #109's guardian revealed he could not remember when he had last been invited to or attended a care conference. He stated he had been her guardian since 2013. Interview on 01/28/20 at 3:56 P.M. with Social Service Director (SSD) #205 confirmed Resident #109's last care conference was 09/04/19 and that her guardian did not attend. SSD #205 stated the guardian was very difficult to get a hold of, but SSD #205 had no evidence of attempting to invite the guardian to the care conference. 3. Review of Resident #22's medical record revealed he admitted to the facility 06/28/12. Diagnoses included dementia with behavioral disturbance, obsessive compulsive disorder, and pseudo-bulbar affect. Review of Resident #22's MDS dated [DATE] revealed he was cognitively intact and required set-up to extensive assistance from staff with activities of daily living. Further review of Resident #22's medical record revealed the last care conference was held on 09/11/19. Interview on 01/28/20 at 4:10 P.M. with SSD #205 confirmed Resident #22's last care conference was 09/11/19. 365514 Page 8 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of closed medical record, interview with facility staff, and review of facility policy, the facility failed to develop a post-discharge plan of care that addressed discharge needs, goals, treatment preferences, caregiver support as well as referrals made to address post-discharge needs. This affected one (Resident #119) of one resident reviewed for appropriate discharge planning. The census was 121. Residents Affected - Few Findings include: Review of Resident #119's closed medical record revealed she admitted to the facility on [DATE]. She discharged to home on [DATE]. Diagnoses included cerebral infarction, dysphagia, major depressive disorder, and delusions. Review of her Minimum Data Set (MDS) dated [DATE] revealed she discharged home to the community. She had a moderate cognitive impairment. She required extensive assistance from staff with bed mobility, transfers, toilet use, and personal hygiene. She was totally dependent on staff for bathing and required limited assistance with eating. Further review of Resident #119's medical record, including her comprehensive care plan, lacked evidence of a discharge plan of care. Interview on 01/29/20 at 10:15 A.M. with Social Service Director (SSD) #205 and Social Service Assistant (SSA) #206 confirmed there was no discharge care plan for Resident #119. They verified discharge care planning was supposed to begin upon admission and be revised as services were coordinated. SSD #205 and SSA #206 confirmed Resident #119's medical record lacked required care-planning information including arranged services for post-discharge including type of services home health would provide (therapy, blood work monitoring, activities of daily living (ADL) assistance), or whether her son, her primary caregiver, was educated on her needs as Resident #119 required extensive assistance with ADLs. Review of a facility policy titled, Transfer and Discharge Policy, effective 03/10/17, revealed the facility was to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents, including a smooth transition of care for discharge or transfer. When a resident's discharge was anticipated, the facility would develop and implement a discharge plan that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Under the heading, Discharge Plan, indicated the discharge plan would include regular re-evaluation of residents to identify changes that required modification of the discharge plan. The discharge plan would consider caregiver/support person availability and the resident's or caregiver's/support person capacity and capability to perform required care, as part of the identification of discharge needs. The plan would involve the resident and resident representative in the development of the discharge plan and inform the resident and representative of the final plan. The discharge plan would address the resident's goals of care and treatment preferences. 365514 Page 9 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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 medical record review, observation, and interview with facility staff, the facility failed to provide set-up assistance with eating. This affected one (Resident #109) of three residents reviewed for activities of daily living (ADLs). The facility identified 100 residents who required at minimum set-up assistance with eating. The census was 121. Residents Affected - Few Findings include: Review of Resident #109's medical record revealed she admitted to the facility 02/16/18. Diagnoses included chronic obstructive pulmonary disease, type 2 diabetes, schizoaffective disorder, and schizoaffective disorder. Review of Resident #109's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had a moderate cognitive impairment and required supervision and one person physical assist with eating. Resident #109 received hospice services. Review of Resident #109's physician orders revealed on 08/29/18 she was ordered a regular diet, with ground meat texture, and regular texture per request. Review of Resident #109's care plan dated 01/15/20 revealed she had an ADL self-care performance deficit and that her level of assistance for ADL's fluctuated from day to day due to her chronic illness. Interventions included providing supervision and set-up from staff to eat. The care plan was revised on 01/28/20, after surveyor observation, to include staff are to ensure silverware was opened and within reach. Staff were to check on Resident #109 throughout the meal to ensure she was eating and offer alternate meal as needed. Observations of Resident #109 on 01/28/20 revealed the following: at 12:50 P.M., Resident #109 was sitting up in bed, her lunch tray was in front of her. Her silverware was still wrapped inside her napkin. Resident #109 had not eaten or drank anything from her tray. At 12:53 P.M., Resident #109 sat with arms folded across her chest, looking at her tray. Resident #109 began attempting to lift her glass of milk off her tray. At 12:55 P.M., Resident #109 continued to attempt to lift her glass of milk off her tray. State Tested Nursing Assistant (STNA) #107 walked passed Resident #109's room, the resident was in the bed closest to the door. At 12:57 P.M., Resident #109 continued to attempt to drink her milk. She had not touched anything on her tray. No staff had entered her room since the beginning of the observation. At 1:00 P.M., Resident #109 dipped her fingers in her milk and began licking the milk off her fingers. At 1:04 P.M., STNA #107 looked in Resident #109's room and then continued walking down the hall without intervention. At 1:05 P.M., Resident #109 dipped her fingers in her milk and licked her fingers. She still had not touched her food. No staff had provided intervention. At 1:07 P.M.-1:13 P.M., Resident #109 attempted to bring her glass of milk to her lips. At 1:13 P.M. she lifted her uncovered hot chocolate from her tray, but could not get it to her lips. She rested the mug of hot chocolate on her stomach. At 1:16 P.M., STNA #107 briefly stopped in Resident #109's entryway and stated, You okay?, the STNA did not wait for a response from Resident #109 and the STNA continued down the hall. The hot chocolate was still been resting on Resident #109's stomach and her meal remained untouched. Her silverware was still wrapped in her napkin. At 1:18 P.M., STNA #107 began collecting other resident's trays. At 1:19 P.M., Resident #109 placed the hot chocolate on her tray and closed her eyes. Her food and beverages remained unconsumed. 365514 Page 10 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/28/20 at 1:20 P.M. with STNA #107 revealed Resident #109's hall tray was delivered at 12:30 P.M. She stated Resident #109 required assistance with set-up for eating, such as setting out her silverware, cutting up her food, and opening any containers, and spreading any condiments. STNA #107 stated after set-up, Resident #109 was usually able to feed herself. STNA #107 stated she did not know who delivered Resident #109's tray, as she had been delivering meals in the dining room at that time. STNA #107 confirmed Resident #109's silverware was tightly wound in her napkin and that Resident #109 was unable to feed herself as set-up assistance had not been provided. STNA #107 verified Resident #109's tray was delivered, around 12:30 P.M., and from 12:50 P.M. to 1:20 P.M., no intervention was provided from staff to ensure Resident #109 was eating. STNA #107 confirmed she had walked passed Resident #109's room and looked in her room twice, but had not noticed her tray was not set up nor that she had not consumed any of her food or beverage. STNA #107 confirmed intervention should have been implemented sooner. STNA #107 asked Resident #109 if she could bring her a warm grilled cheese as her prepared meal was now cold. STNA #107 wiped Resident #109's fingers and left to retrieve a new meal for Resident #109. Interview on 01/28/20 at 1:30 P.M. with the Director of Nursing (DON) confirmed Resident #109 required set-up assistance with eating and her silverware should have been set out. She confirmed Resident #109's care plan indicated her needs related to ADL assistance varied daily related to her multiple chronic conditions and that intervention should have been provided to encourage and assist Resident #109 with consuming her meal. 365514 Page 11 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0692 Provide enough food/fluids to maintain a resident's health. 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, resident and staff interviews, and review of the facility's policy the facility failed to provide fluids when a fluid restriction was discontinued. This affected one (Resident #94) of one resident reviewed for hydration. Facility census was 121. Residents Affected - Few Findings include Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, polydipsia, hypertension, generalized anxiety disorder, and convulsions. Review of the comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #94 was independent in activities of daily living with set up help only. Review of physician orders revealed Resident #94 received a regular diet with regular food texture and thin consistency fluids. A fluid restriction consisting of 2000 cubic centimeters (cc) per 24 hours was ordered on 01/23/19 with fluids to be given as follows: Dietary provided 420 cc of fluid with breakfast, 480 cc with lunch, 240 cc at 2:00 P.M., and 360 cc with dinner and Nursing provided 480 cc of fluid from 7:00 A.M. to 3:00 P.M.,160 cc of fluid from 3:00 P.M. to 11:00 P.M., and 160 cc of fluid from 11:00 P.M. to 7:00 A.M. The fluid restriction was discontinued on 01/28/19. Review of the care plan revealed a care area for behavior problems related to socially inappropriate behavior at times, resisting care and medications, and noncompliance with the fluid restriction. Review of physician progress notes revealed no indication the resident was on a fluid restriction. Review of dietary progress notes revealed no indication Resident #94 was on a fluid restriction. Review of the Hydration assessment dated [DATE] revealed Resident #94's mucus membranes, lips, and tongue were moist. Interview with the Resident #94 on 01/27/20 at 11:08 A.M. revealed the resident would like to have fluids available routinely in his room. Observation at the time of the interview, revealed Resident #94 had no fluids in his room. There were no overt signs of dehydration observed. Interview on 01/29/20 at 9:17 A.M. with Licensed Practical Nurse (LPN) #200 revealed she did not know of any reason the resident would not have water in the room. She verified the resident did not currently have any water in the room. LPN #200 indicated the aides passed water twice a shift and as necessary throughout the day. Interview on 01/29/20 at 9:23 A.M. with State Tested Nursing Assistant (STNA) #201 revealed the STNA passed water at least three times during a 12 hour shift, first thing in the morning, with lunch and dinner, and then as requested. The STNA stated a few residents were on fluid restrictions or received thickened liquids. The STNA indicated at one time Resident #94 was on a fluid restriction. The STNA would look at the resident's care plan or ask the nurse if there were any questions about a resident receiving fluids. 365514 Page 12 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/29/20 at 9:51 A.M. with LPN #203 revealed previously Resident #94 was on a fluid restriction due to obsessively drinking. The LPN verified that, per physician orders, the resident no longer had a fluid restriction in place. Interview with the Director of Nursing (DON) on 01/29/20 at 10:52 A.M. verified the resident was not on a fluid restriction. Review of the facility's policy titled General Hydration Services revised 04/01/16 revealed to provide adequate fluids and provide fresh water at the bedside. The care plan would be updated with any changes. 365514 Page 13 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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 medical record review, observation, staff interview, and manufacturers recommendations review the facility failed to ensure residents were free from significant medication errors. Staff failed to ensure insulin lispro Humalog Kwikpen was primed prior to use according to manufacturer's recommendations. This may cause the resident to get too much or too little insulin. This affected one (Resident #49) of two residents observed for insulin administration. The facility census was 121. Residents Affected - Few Findings include: Medical record review revealed Resident #49 was admitted on [DATE] with pertinent diagnosis of dementia without behavioral disturbance, hypertension, osteoarthritis, hyperlipidemia, major depressive disorder, diabetes mellitus, muscle weakness, and insomnia. Review of the 11/11/19 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. She used a walker and a wheelchair to aid in mobility and was frequently incontinent of both bowel and bladder. Review of a physicians order dated 01/29/20 revealed an order for insulin sliding scale 22 units for blood sugar of 451-500 milligrams/deciliter. Inject 22 units of lispro Humalog Kwikpen subcutaneously to replace insulin aspart Novolog. Observation on 01/29/20 at 8:35 A.M. revealed Licensed Practical Nurse (LPN) #301 administered insulin to Resident #49. LPN #301 turned the dial to 22 units of insulin lispro Humalog Kwikpen and did not prime the pen with two units prior to administration. Interview with LPN #301 on 01/29/20 at 9:39 A.M. verified she did not prime the insulin lispro Humalog Kwikpen for Resident #49. Review of the facility provided manufacturer recommendations instructions for use of insulin Kwikpen dated 10/08/15 revealed to prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than four times. If you still do not see insulin, change the needle and repeat priming steps. 365514 Page 14 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical record, observation, resident and staff interview, and review of facility policy the facility failed to ensure medications were not left at a residents bedside. This affected one (Resident #95) of five residents observed for medication administration. Facility census was 121. Findings include: Review of the medical record revealed Resident #95 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute kidney failure, hypertension, generalized anxiety disorder, and atherosclerotic heart disease. Review of the admission observation tool dated 06/30/19 revealed Resident #95 did not wish to self administer medications. Review of the comprehensive assessment dated [DATE] revealed the resident was cognitively intact. Resident #95 required limited to extensive assistance for activities of daily living. Observation on 01/28/20 at 8:31 A.M. revealed a medication cup containing pudding and a medication was sitting on Resident #95's over bed table. The resident was eating breakfast. Interview at the time of the observation with Resident #95 revealed the resident had difficulty consuming enough calories with meals. The resident did not want to take the medication until breakfast was completed as it would affect the amount of food the resident could eat. The nurse did not normally leave medications in the room for the resident to take. Interview on 01/28/20 at 8:35 A.M. with Licensed Practical Nurse (LPN) #208 revealed Resident #95 was taking the medications when the LPN left the room. The resident took some of the medications, but did not take the potassium. LPN #208 verified the resident should be watched until the medications had been swallowed. The LPN had walked out of the room prior to Resident #95 swallowing all the medications. Review of the facility's policy titled Medication Administration, revised 12/14/17, revealed staff should remain with the resident until the medication was swallowed. The medication was not to be left at the bedside. 365514 Page 15 of 16 365514 01/30/2020 Allen View Healthcare Center 2615 Derr Road Springfield, OH 45503

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 medical record review, observation, staff interview, and review of directions for sani cloth bleach germicidal disposable wipes the facility failed to follow appropriate infection control procedures for the cleaning of the blood glucose monitoring machine after each use to prevent the spread of infections. This affected one (Resident #102) of two residents reviewed for blood glucose monitoring. The facility identified 10 Residents (#9, #16, #36, #37, #48, #49, #53, #54, #56, and #96) who received blood glucose monitoring on the 200 hallway. The facility census was 121. Residents Affected - Some Findings include: Review of the medical record revealed Resident #102 was admitted on [DATE] with pertinent diagnosis of: type two diabetes mellitus, hypertension, hyperlipidemia, cerebral infarction, chronic obstructive pulmonary disease and convulsions. Observation of a blood sugar glucose monitoring check on 01/29/20 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #301 was preparing to check the blood sugar for Resident #102. The Director of Nursing (DON) told LPN #301 she needed to clean the blood glucose monitoring machine prior to use and gave her a bleach germicidal disposable wipe. LPN #301 wiped only the top of the blood glucose monitoring machine for five seconds and then immediately went into Resident #102's room to conduct the blood sugar check. Interview with LPN #301 on 01/29/20 at 9:39 A.M. verified they only use one blood glucose monitoring machine for the hallway. LPN #301 verified she did not clean the entire blood glucose monitoring machine and did not keep the surface wet for four minutes prior to using the blood glucose monitoring machine for Resident #102. Review of the directions on the sani-cloth bleach germicidal disposable wipe box revealed to disinfect use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full four minutes. 365514 Page 16 of 16