Health inspection·October 31, 2019

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement an effective antibiotic (ATB) stewardship program to ensure the proper use of antibiotics. This affected two residents (#31 and #12) residents residing in the facility. Residents Affected - Few Findings include: 1. Resident #31 was admitted to the facility on [DATE] with a diagnosis which included pancreatic cancer. Review of a nursing note, dated 07/23/19 revealed the resident did not have any signs and/or symptoms (s/s) of a urinary tract infection (UTI). Further review revealed the Hospice nurse recommended a urinalysis. Review of the physician's orders, dated 07/25/19 revealed an order to obtain a urinalysis. Review of the urinalysis results received 07/29/19 revealed the resident had one organism present. Review of the physician's orders, dated 07/29/19 revealed an order to start an ATB, Ampicillin 500 milligrams (mg) three times a day (TID) for seven days, for a urinary tract infection. Further review of the medication administrator record (MAR) from 07/29/19 through 08/05/19 revealed the resident received the ATB as ordered. Review of the July 2019 ATB stewardship monthly log revealed there was no indication the resident was on an ATB. Further review revealed there was no McGreer Constitutional Criteria Protocol (MCCP) or ATB use tool completed for the resident. Review of the August 2019 ATB log revealed the resident had a UTI which an ATB was given but the McGreer criteria was not met indicating an ATB was not warranted. There was no evidence of notifying the physician. Review of the nursing notes dated 08/23/19 through 08/26/19 revealed the resident did not have any s/s of an UTI. Further review of the 08/26/19 note indicated the Hospice nurse requested an urinalysis. Review of the nursing note dated 08/29/19 revealed the physician was contacted, ordered ATB and requested the cultures be sent to him when available. Review of the physician's order dated 08/29/19 revealed to start an ATB, Keflex 500 mg three times per day for seven days for UTI. Further review of the MAR revealed the resident received the ATB as ordered. Review of the urinalysis received 08/31/19 revealed the resident had one organism. The report indicated which ATB were effective (sensitivity) in treating the infection and Keflex was not listed. Further review of the handwritten note on the report revealed the resident was to receive the ATB but did not have any s/s of UTI, it was signed and dated 09/03/19. On 10/30/19 at 4:55 P.M., interview with Registered Nurse (RN) #400 revealed the facility used the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365580 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley-Boardman 7148 West Blvd Youngstown, OH 44512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few McGreer protocol for the use of ATBs. RN #400 stated when a resident presented with s/s of a possible infection, the physician was notified. If the physician wanted to order an ATB the nurse talking to the physician was supposed to complete the MCCP and if the criteria was not met, indicating an ATB was not warranted, the physician was to be informed. After completing the MCCP the nurse was to put the assessment in RN #400's mailbox for her to review. She stated it could take up to three days to review. RN #400 stated she would then complete an ATB use tool to ensure the ATB stewardship program was being implemented and was effective. If the physician was not willing to follow the protocol she would attempt to talk to the physician about the requirements. RN #400 verified the MCCP assessments were not being completed when ATBs were being ordered. RN #400 verified residents were receiving ATBs when the McGreer criteria was not met. RN #400 verified there was no evidence the Resident #31 was receiving the ATB in July 2019. RN #400 verified Resident #31 had a positive urinalysis but did not have s/s therefore did not meet the McGreer's criteria for receiving ATBs but the ATB was ordered and there was no evidence the physician was questioned about the use of the ATB. 2. Resident #12 was admitted to the facility on [DATE] with a diagnosis which included heart disease. Review of the nursing notes, dated 08/23/19 through 08/27/19 revealed there was no evidence of s/s of an UTI. Review of the urinalysis collected 08/27/19 and received 09/03/19 revealed a handwritten note stating the UTI was uncomplicated and start ATB. Review of the physician's orders dated 09/03/19 revealed to start an ATB, Levaquin 250 mg at night for three nights for UTI. Further review of the MAR revealed the ATB was given as ordered. Review of the ATB use tool revealed the resident did not met the MCCP criteria for the use of the ATB. Review of the MCCP dated 09/03/19 revealed it did not indicate specifically how and if the resident met the criteria for the use of the ATB. On 10/30/19 at 4:55 P.M., interview with Registered Nurse (RN) #400 revealed the facility used the McGreer protocol for the use of ATBs. RN #400 stated when a resident presented with s/s of a possible infection, the physician was notified. If the physician wanted to order an ATB the nurse talking to the physician was supposed to complete the MCCP and if the criteria was not met, indicating an ATB was not warranted, the physician was to be informed. After completing the MCCP the nurse was to put the assessment in RN #400's mailbox for her to review. She stated it could take up to three days to review. RN #400 stated she would then complete an ATB use tool to ensure the ATB stewardship program was being implemented and was effective. If the physician was not willing to follow the protocol she would attempt to talk to the physician about the requirements. RN #400 verified the MCCP assessments were not being completed when ATBs were being ordered. RN #400 verified residents were receiving ATBs when the McGreer criteria was not met. Review of the ATB stewardship policy, revised 10/01/17, revealed it was to promote the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce ATB resistance. ATB would be prescribed for the correct indication, dose and duration to appropriately treat the resident while attempting to reduce the development of ATB-resistant organisms or other adverse consequences or outcomes. When the nurse suspected the resident had an infection, the nurse would perform (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365580 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley-Boardman 7148 West Blvd Youngstown, OH 44512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete an evaluation of the resident while utilizing the MCCP to determine if any ATB was necessary or if a change in therapy could be needed. Notify the physician of the change of condition and the evaluation information. The nurse would monitor for results of any ordered diagnostics and notify the physician of the results to ensure the resident was taking the appropriate ATB or if ATB needs to be discontinued or changed. If indicated, based on the criteria, an ATB would be ordered, the physician would identify the diagnosis, the appropriate ATB, proper dose, duration and route. In the event the physician ordered an ATB without identification of the infection criteria, the physician would be requested to identify rationale for ordered ATB. The medical director would be contacted for further direction. If the resident was admitted to the facility an ATB ordered, the nurse would identify the indication for the use, documentation for dose, route, duration, effectiveness and potential adverse consequences. The infection preventions would track ATB use an monitor adherence to evidence-based criteria. During the monthly quality improvement committee meeting ATB use would be analyzed and any potential action plans related to the analysis of the tracking and trending would be implemented. Event ID: Facility ID: 365580 If continuation sheet Page 4 of 4