Health inspection·April 4, 2019

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, personal funds account review, facility policy review, family and staff interview, the facility failed to promptly notify the resident's representative when the resident's account reached $200 less than the maximum amount permitted a recipient for Medicaid. This affected one (Resident #32) of four residents reviewed for personal funds. This had the potential to affect twenty-eight residents with personal funds accounts. The facility census was 61. Residents Affected - Few Findings include: Review of medical record for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease, malignant neoplasm of the frontal lobe and hemiplegia following a cerebral vascular infarction. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/06/19, revealed the resident had impaired cognition. Review of Resident #32's account balances from 04/10/18 through 04/01/19 revealed the following amounts: 04/23/18 $1,926.47 04/30/18 $1,926.63 05/31/18 $2,248.79 06/15/18 $2,570.79 07/31/18 $2,892.97 08/21/18 $3,214.97 09/30/18 $3,537.39 10/31/18 $3,859.65 11/30/18 $4,181.96 12/31/18 $4,504.27 Page 1 of 3 365538 365538 04/04/2019 Friends Extended Care Center 150 East Herman Street Yellow Springs, OH 45387

F 0569 04/01/19 $5, 083.81 Level of Harm - Minimal harm or potential for actual harm Interview on 04/01/19 at 4:30 P.M. with Administrative Accounts Payable staff (AAP) #53 revealed Resident #32 with an account balance of $5,083.81. AAP #53 confirmed a quarterly statement was sent to the resident's representative for the time-period of 10/09/18 through 12/31/19. AAP #53 identified a line on the bottom of the quarterly statement which identified Resident #32's account was over the amount necessary to remain Medicaid eligible. The statement requested the resident's representative to contact the Licensed Social Worker. Residents Affected - Few Interview on 04/02/19 at 10:10 A.M. with Social Worker (SW) #85 revealed she was not aware of the statement on the bottom of the quarterly statement. SW #85 additionally stated she has never followed up on any personal funds accounts for any reason. Telephone interview on 04/04/19 at 10:57 A.M. with Resident #32's Power of Attorney (POA) did confirm knowledge Resident #32 being over the maximum amount. Resident #32 confirmed receiving quarterly statements which had a notice informing that Resident #32 exceeded the amount necessary to remain Medicaid eligible. Interview on 04/04/19 at 11:17 A.M. with Administrator confirmed no additional notifications were sent to Resident #32's other than the quarterly statements. Administrator confirmed resident was within the $200 dollars of exceeding the maximum amount on 04/23/19. Resident #32's representative did not receive a notice of spend down until 06/30/19 when the quarterly statements were mailed. Review of the facility policy titled, Management of Resident's Personal Funds dated March of 2017 reveals if the facility manages the resident's funds, the facility will act as a fiduciary of the resident fund and hold, safeguard, manage and account for the personal funds of the resident. 365538 Page 2 of 3 365538 04/04/2019 Friends Extended Care Center 150 East Herman Street Yellow Springs, OH 45387

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 record review and staff interview, the facility failed to ensure a resident had a valid Ohio Comfort Care Do Not Resuscitate order. This affected one (Resident #24) of twenty-four residents reviewed during first stage of the survey. The facility census was 61. Findings include: Review of Resident #24's medical record revealed being admitted on [DATE] with diagnoses including Alzheimer's Disease, depression, anxiety and dementia. Review of the Minimum Data Set (MDS) assessment, dated 01/17/19, revealed the resident had a severe cognitive deficit. Review of Resident #24's undated Ohio Do Not Resuscitate (DNR) Comfort Care form revealed resident was a Do Not Resuscitate Comfort Care -Arrest (DNRCC-A). The form had resident's name, address and signature of resident's Power of Attorney. However, it did not have the physician's signature. The form did have a notation at the bottom of having been faxed to the physician on 12/16/18. Interview on 04/01/19 at 3:50 P.M. with Licensed Practical Nurse (LPN) #58 confirmed Resident #24's Ohio DNR Comfort Care order did not have a physician's signature. LPN #58 was not able to provide a signed form for Resident #24. Interview on 04/02/19 at 3:50 P.M. with Director of Nursing confirmed Resident #24 did not have a signed Ohio DNR Comfort Care Arrest order. Review of the facility policy titled, Advanced Directives, dated 10/29/15, revealed the nurse will notify the attending physician of the advance directives so that the appropriate orders can be documented in the resident's medical record. 365538 Page 3 of 3