Health inspection·December 12, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, observation, and staff interview, the facility failed to develop and/or implement each resident's plan of care related to contracture management, diabetes management and insulin use, use of an anti-platelet medication, and for medications used to managed inappropriate behaviors. This affected four (#04, #07, #52, and #63) of 20 residents' whose care plans were reviewed. The census was 66 residents. Findings include: 1. Review of the medical record revealed Resident #04 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, anxiety disorder, major depressive disorder, hypertension, and dysphagia. The facility completed a quarterly minimum data set (MDS) assessment of Resident #04's cognitive and physical functional status dated 09/02/19. The resident was identified as having moderate cognitive deficits, and being dependent on one to two staff person for all of her activities of daily living. The resident was assessed as having functional limitations in her range of motion to both of her upper and lower extremities. Review of Resident #04's current physician's orders revealed an order on 12/03/19 as follows: may use bilateral palm pillow orthotic twice a day for up to four hours (personal caregiver may do) as tolerated Review of nursing progress notes revealed an entry by Licensed Practical Nurse (LPN) #15 on 12/03/19. LPN #15 documented Occupational Therapy (OT) clarified to staff to don the resident with the bilateral palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M. Daily skin check and range of motion to be completed. Review of Resident #04's current plan of care through 12/12/19 revealed a plan of to address the resident's problem/need related to bilateral contractures of her hand and feet. The goal was for the resident to be comfortable and have relief through the next review. The new interventions relating to the application of the palm pillows daily had not been added as of 12/09/19. On 12/10/19 at 10:16 A.M., LPN #11 was asked to view Resident #04's hands, with the resident's permission. Resident #4 smiled and stated yes. The resident was observed with severe contractures of the wrist and hands, with her fingers directed downward, and her fingernails were very long. There were no palm pillows/protectors evident. LPN #11 did not voice awareness that the palm pillows were Page 1 of 9 365595 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0656 supposed to be in place at that time, but did note the resident's fingernails were long. Level of Harm - Minimal harm or potential for actual harm On 12/10/19 at 12:51 P.M., State Tested Nurse Aide (STNA) #36 who was caring for Resident #04 at that time was asked if the resident every wore any protective devices to her hands, like palm protectors or palm pillows. STNA #36 stated that the resident did not wear any devices in her hands, that she was never told anything about any devices for the resident. She shared that she had taken care of the resident at a previous facility where the resident did have something for her hands/palms. STNA #36 was then asked to view the resident's hands with permission from the resident. Resident #4 gave permission, and STNA #36 gloved and showed this surveyor the resident's hands. The nurse aide affirmed the resident did not have any palm pillows present, and there was white matter in her palms and at the base of her thumb. Resident #04 was asked at that time if she had been wearing any thing in her hands that morning, and the resident stated no. Residents Affected - Some Review of the care card (Kardex) sheet for Resident #04 revealed an entry at the bottom written in pencil regarding the palm pillows. The penciled in entry was not dated, and did not specify a wearing schedule. The entry only specified that the resident may use bilateral palm pillow orthotic twice daily up to four hours, and personal caregiver may apply. The Kardex entry did not specify if it was four hours total daily, or four hours at wearing interval, or the specified hours to be worn. An interview was conducted with Resident #04's personal caregiver on 12/10/19 at 6:06 P.M. The personal caregiver explained she or another caregiver was with the resident about 8 hours a day, seven days a week. She stated the resident did have palm pillows but they were too large, they slide off. The caregiver shared that the resident either needed a smaller version, or Velcro needed to be added to make the palm pillows smaller. She then pointed to instructions regarding the palm pillows taped to the wall in the resident room, stating that it was just posted this past week. The posted scheduled specified the resident was to wear the palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M. An interview was conducted with Certified Occupational Therapy Aide (COTA) # 89 on 12/11/19 at 11:42 A.M. regarding Resident #04's palm pillows. She affirmed the resident was discharged from OT on 12/02/19, and was supposed to be wearing the palm pillows twice a day for up to four hours each time. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, protein calorie malnutrition, coronary atherosclerosis due to calcified coronary lesion, hyperglycermia, and hypertension. The facility completed a quarterly MDS assessment of the resident's cognitive status dated 11/04/19. The resident was assessed as having moderate cognitive impairment, but was alert to himself, place, time, and situation on interview on 12/09/19. Review of Resident #52's current physician's order revealed the resident had an order to receive 75 milligrams (mg)of Clopidagrel daily, a medication to inhibit platelet aggregation. Review of Resident #52's comprehensive plan of care failed to reveal a plan of care to address the resident's potential or current problems/needs related to the use of the anti-platelet medication. During interview with Resident #52 on 12/09/19 at 1:15 P.M. the resident expressed concerns regarding a few red circular bruised areas on both arms. The resident indicated he noticed it a few weeks ago and also shared that he had fallen recently. 365595 Page 2 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with LPN #15 on 12/11/19 at 10:23 A.M. regarding Resident #52's concerns about the red areas/bruising on his arms. She reported the resident had a fall, and also had blood work recently. LPN #15 stated the resident was on a medication, and named an anticoagulant medication not an anti-platelet medication, and that it took a long time for his bruises to resolve. An interview was conducted with MDS nurse, Registered Nurse (RN) #05 on 12/11/19 at 4:34 P.M. regarding the lack of a plan of care for Resident #52's use of an anti-platelet medication. RN #05 reviewed the resident's care plan and affirmed there was no care plan to address the potential problems/needs related to the resident's use of the anti-platelet medication and it should have been care planned. 3. Resident #63 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, psychotic disorder with delusions, mood disorder, hypertension, major depressive disorder, and age related osteoporosis. The facility completed a comprehensive assessment of Resident #63's cognitive and physical functional status on 11/15/19. The 11/15/19 assessment identified the resident as having short and long term memory problems, inattention, disorganized thinking, and requiring the physical assistance of at least one staff person to complete all activities of daily living. Review of Resident #63's current physician's orders, and November and December 2019, medication administration record revealed the resident was receiving short acting Novolog insulin four times daily as needed per sliding scale, and long acting Levimir insulin each morning. Review of Resident #63's comprehensive plan of care failed to reveal any care plan regarding the resident's problems/needs related to use of insulin subsequent to her diagnoses of diabetes mellitus. On 12/02/19 RN #125 made an entry into Resident #63's progress notes. RN #125 noted a new physician order to change the Levemir to morning dosing to 100 units a day, and to add a sliding scale at bedtime of Novolog related to type 2 diabetes mellitus, and to fax the blood sugars next Monday. An interview was conducted with LPN #15 on 12/12/19 at 12:47 P.M. regarding Resident #63's new insulin orders. She reported the resident did received short acting insulin as needed per sliding scale with meals and at bedtime, and long acting insulin also. She shared the resident's physician recently changed the long acting insulin Levemir from evening to morning as the resident's morning blood sugar was running low. On 12/11/19 at 2:10 P.M. MDS nurse, RN #05 was asked to review Resident #63's plan of care for any care plan which addressed the resident's use of insulin and diabetes management. RN #05 reviewed the care plan and affirmed no care plan had been developed related to the resident's need for insulin and management of her diabetes. 4. Review of Resident #07's medical record revealed an admission date of 09/17/15 with diagnoses including dementia with behavioral disturbance, major depressive disorder and anxiety disorder. Review of Resident #07's MDS dated [DATE] revealed the resident required supervision for bed mobility and transfer. The resident required extensive one-person assistance for dressing, personal hygiene and toileting. The resident was independent with eating. The resident had no identified behaviors. 365595 Page 3 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident #07's plan of care dated 09/05/19 revealed no focus or interventions related to inappropriate sexual behaviors or for the use of the medication Medroxyprogesterone (Provera). Review of Resident #07's physician order dated 09/17/15 revealed Medroxyprogesterone Acetate 10 milligram (mg)tablet. Give one tablet by mouth one time a day for sexually inappropriate behavior. Residents Affected - Some Review of the Resident #07's physician progress note dated 11/14/19 identified the resident remained on Provera 10 mg for sexually inappropriate behaviors. Physician's progress note was silent for any recent reported sexual behavior. Interview on 12/12/19 at 1:22 P.M. with MDS RN #05 confirmed she had not included interventions for the Provera or for the sexually inappropriate behavior. RN #05 confirmed she was not aware of any sexual behaviors in the past year. Interview on 12/12/19 at 1:33 P.M. with LPN #01 revealed having knowledge of the resident. LPN #01 denied Resident #07 had any sexually inappropriate behaviors in the past year. Interview on 12/12/19 at 3:40 P.M. with the Director of Nursing (DON) denied the facility was monitoring Resident #07 for sexual behaviors. 365595 Page 4 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 representative/family interview and staff interview, the facility failed to ensure that one resident received treatment and care to maintain proper and comfortable positioning while in a wheel chair. This affected one (Resident #16) of three residents reviewed for positioning/mobility. Residents Affected - Few Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, moderate protein calorie malnutrition (PCM), dementia with behavioral disturbance, anxiety disorder, repeated falls, dysphagia, and bilateral hearing loss. The resident was admitted to in-facility hospice services on 11/15/19 with an admitting diagnoses of PCM. The facility completed an admission minimum data set (MDS) assessment of the resident's cognitive and physical functional status on 09/18/19. The 09/18/19 assessment identified the resident as having short and long term memory problems with severely impaired cognitive skills, and requiring limited to extensive assistance by one to two staff persons to completed all activities of daily living. The resident utilized a wheel chair propelled by others for mobility. Review of Resident #16's physician's orders revealed an order date 11/12/19 for the resident to utilize a high back tilt-in-space wheel chair with a lap tray at all times. The order specified for the lap tray to be removed for 10-15 minutes ever two hours, and the resident must be supervised during that time. While there was an assessment evident for Resident #16's use of the lap tray in an existing wheel chair on 10/18/19. There was no re-assessment evident in the medical record prior regarding the use of the new high back tilt-in-space wheel chair with lap tray ordered on 11/12/19 related to the resident's positioning and comfort in the new wheel chair. Resident #16 was observed passively attending an activity in the large activity room on 12/09/19 at 9:47 A.M. The resident was seated in a high back wheel chair with a padded lap tray and foot rests. The resident did not keep her feet in the foot rests, and her feet were dangling underneath the chair and her toes barely touched the floor. Resident #16 was wearing non-skid socks. On 12/09/19 at 1:47 P.M. an interview was conducted with Resident #16's representative/family member. The family member was questioned about the high back wheel chair and lap tray, and was asked if the resident was comfortable in the chair. The family member shared that the resident's feet dangle somewhat in the chair, and that they barely touched the floor, and to him that would probably be uncomfortable. ON 12/10/19 at 4:34 P.M. Resident #16 was observed up in the common area near the 200/300 nursing station in the high back wheel chair with the lap tray in place. The residents knees hung down from the wheel chair seat which had pads, and her ankle extended, with only her toes touching the floor. The resident was not able to propel the chair on her own, and was not able to answer questions regarding her comfort at that time due to her advanced dementia. Resident #16 remained up in the wheel chair near the nursing station until at least 6:09 P.M. with her feet dangling under the chair and toes pointed downward. 365595 Page 5 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/11/9 at 11:30 A.M. Certified Occupational Therapy Assistant (COTA) #89 was asked to check to see if Resident #16 had received any OT evaluation or treatment for wheel chair management/positioning. She reported that she had not, and potentially was not referred to OT as she was receiving hospice care, and the chair was most likely ordered by nursing or hospice. COTA #89 was then asked to observe the resident with this surveyor, and asked about the fit of the wheel chair related to the resident's comfort and positioning. She affirmed the residents feet dangled while in the chair, and did not fully touch the floor, and that the resident did not keep her feet in the foot rests. COTA #89 was questioned regarding potential negative consequences from the poor positioning, and affirmed it could potentially result in flexion contractures of the knee, and lead to foot drop. An interview was conducted with the Director of Nursing (DON) on 12/11/19 at 5:45 P.M. regarding Resident #16's positioning, and the resident was observed with the DON. The DON affirmed the resident's feet did not touch the floor and that she would not use the foot rests. She also affirmed there was no assessment evident in the medical record of the resident's positioning/comfort in the high back wheel chair. On 12/11/19 at 5:59 P.M. a nurse documented in Resident #16's nursing progress noted that there was a new order received from the hospice provider for the resident to have a foot cradle to the wheel chair for leg/foot positioning. 365595 Page 6 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure that a resident with a limited range of motion received appropriate treatment to prevent further decreases in range of motion and to improve comfort. This involved one (Resident #04) of three residents reviewed for positioning/mobility. Findings include: Review of the medical record revealed Resident #04 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anxiety disorder, major depressive disorder, hypertension, and dysphagia. The facility completed a quarterly minimum data set (MDS) assessment of Resident #04's cognitive and physical functional status dated 09/02/19. The resident was identified as having moderate cognitive deficits, and being dependent on one to two staff person for all of her activities of daily living. The resident was assessed as having functional limitations in her range of motion to both of her upper and lower extremities. Review of Resident #04's current physician's orders revealed an order on 12/03/19 as follows: may use bilateral palm pillow orthotic twice a day for up to four hours (personal caregiver may do) as tolerated Review of nursing progress notes revealed an entry by Licensed Practical Nurse (LPN) #15 on 12/03/19. LPN #15 documented that Occupational Therapy (OT) clarified to staff to don the resident with the bilateral palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M. Daily skin checked and range of motion to be completed. Review of Resident #04's current plan of care through 12/12/19 revealed a plan to address the resident's problem/need related to bilateral contractures of her hand and feet. The goal was for the resident to be comfortable and have relief through the next review 12/12/19. The new interventions related to the application of the palm pillows daily had not been added as of 12/09/19. On 12/10/19 at 10:16 A.M. LPN #11 was asked to view Resident #04's hands, with the resident's permission. Resident #04 smiled and stated yes. The resident was observed with severe contractures of the wrist and hands, with her fingers directed downward, and her fingernails were very long. There were no palm pillows/protectors evident. LPN #11 did not voice awareness that the palm pillows were supposed to be in place at that time, but did note the resident's fingernails were long. On 12/10/19 at 12:51 P.M. State Tested Nurse Aide (STNA) #36 who was caring for Resident #04 at that time was asked if the resident every wore any protective devices to her hands, like palm protectors or palm pillows. STNA #36 stated that the resident did not wear any devices in her hands, that she was never told anything about any devices for the resident. She shared that she had taken care of the resident at a previous facility where the resident did have something for her hands/palms. STNA #36 was then asked to view the resident's hands with permission from the resident. Resident #04 gave permission, and STNA #36 gloved and showed this surveyor the residents hands. The nurse aide affirmed the resident did not have any palm pillows present, and there was white matter in her palms and at 365595 Page 7 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the base of her thumb. Resident #04 was asked at that time if she had been wearing any thing in her hands that morning, and the resident stated no. Review of the care card ([NAME]) sheet for Resident #04 revealed an entry at the bottom written in pencil regarding the palm pillows. The penciled in entry was not dated, and did not specify a wearing schedule. The entry only specified that the resident may use bilateral palm pillow orthotic twice daily up to four hours, and personal caregiver may apply. The [NAME] entry did not specify if it was four hours total daily, or four hours at wearing interval, or the specified hours to be worn. An interview was conducted with Resident #04's personal caregiver on 1210/19 at 6:06 P.M. The personal caregiver explained she or another caregiver was with the resident about eight hours a day, seven days a week. She stated the resident did have palm pillows but they were too large, and they slide off. The caregiver shared that the resident either needed a smaller version, or Velcro needed to be added to make the palm pillows smaller. She then pointed to instructions regarding the palm pillows taped to the wall in the resident room, stating that it was just posted this past week. The posted scheduled specified the resident was to wear the palm pillows from 9:00 A.M. through 1:00 P.M., and 3:00 P.M. through 7:00 P.M. An interview was conducted with Certified Occupational Therapy Aide (COTA) #89 on 12/11/19 at 11:42 A.M. regarding Resident #04's palm pillows. She affirmed the resident was discharged from OT on 12/02/19, and was supposed to be wearing the palm pillows twice a day for up to four hours each time. 365595 Page 8 of 9 365595 12/12/2019 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

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 a resident was monitored for sexual behaviors related to the use of medication. This affected one (Resident #07) of six residents reviewed for unnecessary medications. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #07's medical record revealed an admission date of 09/17/15 with diagnoses including dementia with behavioral disturbance, major depressive disorder and anxiety disorder. Review of Resident #07's Minimum Data Set (MDS) dated [DATE] revealed the resident required supervision for bed mobility and transfer. The resident required extensive one-person assistance for dressing, personal hygiene and toileting. The resident was independent with eating. Resident #07's had no identified behaviors. Review of Resident #07's plan of care dated 09/05/19 revealed no focus or interventions related to inappropriate sexual behaviors or the medication Medroxyprogesterone (Provera). Review of Resident #07's physician order dated 09/17/15 revealed Medroxyprogesterone Acetate 10 milligram (mg) tablet. Give one tablet by mouth one time a day for sexually inappropriate behavior. Review of the Resident #07's Physician progress note dated 11/14/19 identified the resident remained on Provera 10 mg for sexually inappropriate behaviors. Physician's progress note was silent for any recent reported sexual behavior. Interview on 12/12/19 at 1:22 P.M. with MDS Registered Nurse (RN) #05 confirmed she had not included interventions for the Provera or for the sexually inappropriate behavior. RN #05 confirmed she was not aware of any sexual behaviors in the past year. Interview on 12/12/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) # 01 revealed having knowledge of the resident. LPN #01 denied Resident #7 had any sexually inappropriate behaviors in the past year. Interview on 12/12/19 at 3:40 P.M. with the Director of Nursing (DON) denied the facility was monitoring Resident #07 for the sexual behaviors. 365595 Page 9 of 9