Health inspection·September 19, 2022

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. Based on medical record review, staff interview, and policy review, the facility failed to ensure resident care plans addressed their smoking and activity needs. This affected one (Resident #39) out of 24 residents reviewed for care planning. The facility census was 74. Findings include: Review of the medical record of Resident #39 revealed an admission date of 07/15/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease with acute exacerbation, metabolic encephalopathy, type two diabetes mellitus with diabetic neuropathy, depression, and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/22, revealed Resident #39 had intact cognition. The assessment further revealed Resident #39 required supervision for bed mobility, transfers, eating, and toileting. Review of a smoking evaluation, dated 08/18/22, revealed Resident #39 was assessed as safe to smoke independently. Review of the Activity Evaluation, dated 07/18/22, revealed Resident #39 indicated it was somewhat important to do things with groups of people and very important to do favorite activities. Favorite activities included television, playing games, and going outside. Resident #39 indicated he preferred to participate in activities in the morning and afternoon and preferred to do activities in his room. Past and current interests included games, sports, music, spending time outdoors, watching television, listening to radio, and talking/conversing. Review the Care Plan for Resident #39 revealed the resident did not have care plans for smoking or activities. Interview on 09/14/22 at 9:17 A.M., with the Director of Nursing (DON) verified Resident #39 did not have a care plan for activities or smoking. The DON further verified all residents who smoke should have a smoking care plan. Review of the facility policy titled, Smoking Policy, dated 07/13/22, revealed the resident's care plan should reflect the resident is a smoker, the degree of supervision necessary, if the resident is to wear a protective smoking vest/apron, and the education and options for smoking cessation activities offered to the resident. Page 1 of 10 365598 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Activities Program, dated 08/16/21, revealed the facility would provide an ongoing activity/recreation program based on the individual resident comprehensive evaluation, care plan, and stated preferences. Residents Affected - Few 365598 Page 2 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to timely complete a thorough fall investigation to determine the root cause of a fall. This affected one (Resident #43) out of four residents reviewed for falls. The facility census was 74. Findings include: Review of the medical record revealed Resident #43 admitted to the facility on [DATE] with diagnoses which included but were not limited to displaced intertrochanteric fracture of the right femur, late onset Alzheimer's disease, type two diabetes, chronic systolic congestive heart failure, and unspecified anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/29/22, revealed Resident #43 had moderately impaired cognition and had no behaviors. Resident #43 was a one-person assist and required extensive assistance with dressing, limited assistance with walking, and supervision with bed mobility, transfers, toileting, eating, and personal hygiene. Review of the Care Plan, dated 07/23/22, revealed Resident #43 was at risk for falls and fall-related injuries related to impaired communication, impaired cognition, use of assistive devices, decreased mobility, medications, and diagnoses including history of fall with right femur fracture, Alzheimer's dementia, diabetes mellitus with neuropathy, hyperlipidemia, hypertension, anemia, osteoarthritis, congestive heart failure, anxiety, depression, gastro-esophageal reflux disease, osteoporosis, and constipation. Interventions included medications as ordered, monitor for/report side effects of medications, monitor labs, encourage appropriate footwear, encourage rest periods, orient to surroundings as needed, therapy evaluations as needed, and keep call light in reach/encourage to use call light. Review of Resident #43's physician progress note, dated 09/13/22, revealed Resident #43 was seen by the medical doctor on 08/29/22 at the nurse's request because she had recently fallen and had a black eye. Review of subsequent visits made on 09/05/22, 09/06/22, 09/09/22, and 09/13/22, revealed Resident #43's ecchymosis to the right eye had improved and was almost resolved. Review of Resident #43's progress notes revealed no documentation of falls or facial bruising. During interviews conducted concurrently on 09/12/22 at 10:25 A.M., Resident #43 stated someone told her she had a bruise on her right cheek but she did not know how she obtained it. Licensed Practical Nurse (LPN) #65, who was seated at a desk, stated Resident #43 had a hypoglycemic episode last week during which she was thrashing in bed and the nurse thought she might have hit her face on the bed frame. LPN #65 stated Resident #43 had a black eye, and went to the hospital for evaluation, because she had hypoglycemic episodes two days in a row and had to have intramuscular glucagon injections. During an interview on 09/15/22 at 11:40 A.M., LPN #65 stated she had never witnessed Resident #43 on the floor. When she came in on the morning of 08/26/22 (Friday), Resident #43 was thrashing in bed and it was not reported to her that Resident #43 had been on the floor. She sent Resident #43 out to the hospital but did not notice the bruise on her face until she returned to work the following 365598 Page 3 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0689 Monday morning. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/14/22 at 3:39 P.M., Assistant Director of Nursing #51 stated State Tested Nurse Aide (STNA) #54 found Resident #43 on the floor, thrashing around. There was no fall packet completed because it was not considered a fall. Residents Affected - Few During an interview on 09/15/22 at 7:56 A.M., STNA #54 stated on 08/26/22, STNA #54 was checking on her assigned residents when she came in at 6:00 A.M. and found Resident #43 on the floor by her bed on the left side of the bed. Resident #43 was on her back and her face was resting on the nightstand at about her eye-brow level. Resident #43 had a little indentation above her eye. STNA #54 stated she did not move the resident. STNA #54 stated she came out and got LPN #65 who came in and checked her. About three or four other people, unidentified, came in and then staff put her back in bed. Resident #43 was not thrashing, she was mumbling with her eyes closed and was out of it so bad. Staff sent Resident #43 out to the hospital. STNA #54 didn't come back until Tuesday (08/30/22) and noticed Resident #43 had a black eye and bruising down her face. STNA #54 stated she was surprised such a little indentation could cause such a big bruise. During an interview on 09/15/22 at 8:08 A.M., the Director of Nursing (DON) stated she was on vacation at the time of Resident #43's incident. To her understanding, the aide found Resident #43 on the floor with her face resting against the nightstand. The nurse's responded appropriately and took care of the emergent situation. LPN #40 stated they didn't consider it a fall because they don't know what happened. She could have been kneeling on the floor when she had her episode. Both the DON and LPN #40 defined a fall as a change of plane and verified there was no fall documentation or incident report completed. Review of policy titled Fall Management, dated 08/18/22, revealed the facility identified the term fall as a resident unintentionally coming to rest on the floor. The policy further stated unless there was evidence suggesting otherwise, when a resident was found on the floor, it was considered a fall. In the event of a fall, the interdisciplinary team conducted an evaluation to ensure appropriate measures were in place to minimize the risks of future falls, and the DON was responsible to coordinate the process for prediction, risk evaluation, treatment, evaluation, and monitoring of resident falls. 365598 Page 4 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 2. Review of the medical record of Resident #59 revealed an admission date of 08/22/20. Diagnoses included diabetes, edema, breast cancer, congested heart failure, and peripheral vascular disease. Residents Affected - Few Review of the pharmacy consultation report, dated 03/10/22, revealed Resident #59 received sliding scale insulin for the treatment of diabetes since July 2021 with a hemoglobin A1C level (measures average blood sugar levels over the past three months) drawn in December 2021. A new recommendation was made by the pharmacist to discontinue the sliding scale insulin and initiate alternative antidiabetic therapy. There was no physician signature and the recommendation was not addressed. Resident #59's medical record did not reflect a discontinuation of the sliding scale insulin. Review of the pharmacy consultation report, dated 05/09/22, revealed Resident #59 received Ibuprofen Tablet 800 milligrams every eight hours as needed. There was a new pharmacist recommendation to consider discontinuation of Resident #59's Ibuprofen. Review of Resident #59's August 2022 physician orders revealed the Ibuprofen Tablet 800 milligrams every eight hours as needed was discontinued on 08/23/22. Review of the pharmacy consultation report, dated 06/05/22, revealed Resident #59 received Icy Hot liquid three times a day as a treatment. There was a new pharmacist recommendation to consider discontinuation of the Icy Hot treatment. Review of Resident #59's August 2022 physician orders revealed the Icy Hot treatment was discontinued on 08/23/22. Interview on 09/15/22 at 8:17 A.M., with the DON confirmed Resident #59's pharmacy recommendations were not addressed in a timely manner. Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two (#39 and #59) out of five residents reviewed for unnecessary medications. The facility census was 74. Findings include: 1. Review of the medical record of Resident #39 revealed an admission date of 07/15/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease with acute exacerbation, type two diabetes mellitus with diabetic neuropathy, depression, and dementia without behavioral disturbance. Review of a pharmacy consultation reports for 07/17/22, revealed Resident #39 was receiving three or more CNS (central nervous system) active medications which can cause an increased risk for falls and fractures: fluoxetine (selective serotonin reuptake inhibitor) 20 milligrams (mg) once a day, buproprion (antidepressant medication) XL 300 mg once a day, morphine sulfate (medication used to relieve moderate to severe pain) ER 60 mg twice a day, pregabalin (nerve pain medication) 100 mg once a day and 300 mg every 12 hours (over the recommended max dose). Recommendations were to re-evaluate the combination and reduce the dose of one of the medications with the end goal of discontinuation. The consultation report was not signed and was not addressed. 365598 Page 5 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0756 Level of Harm - Minimal harm or potential for actual harm Review of a second pharmacy consultation reports for 07/17/22, revealed Resident #39 routinely received an opiod analgesic, Morphine Sulfate extended release (ER) 60 mg twice a day without a stimulant laxative. Recommendations were made to initiate senna 8.6 mg, two tablets once daily at bedtime (hold for loose stools), while continuing to monitor for signs and symptoms of constipation. The consultation report was not signed and was not addressed. Residents Affected - Few Review of Resident #39's medical record revealed the next pharmacy regimen review took place on 08/16/22. Review of Resident #39's physician orders revealed an order, dated 07/15/22, for Lyrica Capsule 300 mg, give one capsule by mouth every 12 hours for neuropathy pain. Review of Resident #39's physician orders revealed an order, dated 07/15/22, for MS Contin Tablet Extended Release 60 mg (Morphine Sulfate ER), give 60 mg by mouth two times a day for pain. Review of Resident #39's physician orders revealed an order, dated 07/16/22, for Buproprion HCl extended release (ER) (XL) Tablet Extended Release 24-hour, give 300 mg by mouth in the morning for depression. Review of Resident #39's physician orders revealed an order, dated 07/16/22, for Fluoxetine HCl (Prozac) Capsule, give 20 mg by mouth one time a day for depression. Review of Resident #39's physician orders revealed an order, dated 07/16/22, with a discontinue date of 09/13/22, for Lyrica (Pregabalin) 100 mg, give one capsule by mouth one time a day for neuropathy pain. Review of Resident #39's physician orders revealed an order, dated 09/13/22, with a start date of 09/17/22, for Senna (Sennosides) 8.6 mg, give two tablets by mouth at bedtime for constipation. Review of Resident #39's physician orders revealed an order, dated 09/14/22, for Lyrica Capsule (Pregabalin) 75 mg, give one capsule by mouth one time a day for neuro pain. Interview on 09/14/22 at 9:17 A.M., with the Director of Nursing (DON) confirmed Resident #39's pharmacy recommendations were not addressed in a timely manner and orders were entered after the recommendations were requested by the surveyor. Review of the facility policy titled Medication Regimen Review, dated 03/03/20, revealed the attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, per applicable regulation. 365598 Page 6 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

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, staff interview, and policy review, the facility failed to ensure residents were free from unnecessary medications. This affected one (#47) out of three residents reviewed for hospitalization. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record of Resident #47 revealed an admission date of 06/04/22. Resident #47 transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with other skin complications, sepsis, and acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #47 had intact cognition. Review of the July 2022 Documentation Survey Report revealed Resident #47 had large-sized loose stools on 07/10/22, 07/11/22, 07/13/22, and 07/14/22. Review of a progress note, dated 07/12/22, revealed Resident #47 was having nausea and diarrhea. The progress note further revealed orders were received to collect stool for clostridium difficile as well as an order for loperamide (anti-diarrheal medication) two milligrams (mg), give two tablets, then one tablet after each episode of diarrhea up to four in a 24-hour period. Review of Resident #47's July 2022 Medication Administration Record (MAR) revealed the nurses signed to indicate Resident #47 received Senna-docusate sodium tablet 8.6-50 mg, two tablets at bedtime on 07/10/22, 07/11/22, 07/12/22, and 07/13/22, and Loperamide two mg, two tablets on 07/12/22 at 3:21 P.M. Interview on 09/14/22 at 12:50 P.M. with Nurse Practitioner (NP) #300 revealed it would be her assumption that the nurse would hold the senna when Resident #47 had loose stools. NP #300 further revealed she would like for the senna to be held when a resident is having loose stools. Interview on 09/14/22 at 3:53 P.M., with the Director of Nursing verified Resident #47's senna was not held when Resident #47 had loose stools and was administered loperamide on 07/12/22. Review of the facility policy titled Medication Regimen Review, dated 03/03/20, revealed the facility should independently review each resident's medication regimen directly from the resident's medical chart as needed. 365598 Page 7 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation and staff interview, the facility failed to ensure medications in the medication storage room were not expired. This had the potential to affect all 74 residents who received medications from the medication storage room. The facility census was 74. Findings include: Observation of the medication storage room on 09/14/22 at 9:42 A.M. revealed there were expired medications in the medication storage room. The expired medications included two bottles of Calcitrate with an expiration date of October 2021, one eight ounce bottle of Senna syrup with an expiration date of October 2021, one 100 tablet bottle of Aspirin 325 milligram (MG) with an expiration date of February 2022, two 100 tablet bottles of Aspirin 325 MG with an expiration date of July 2022, one 100 tablet bottle of Rena Vite with an expiration date of May 2022, and two 16 ounce bottles of liquid acetaminophen with an expiration date of November 2021. Interview on 09/14/22 at 9:43 A.M. with Licensed Practical Nurse (LPN) #6 confirmed the above expired medications were in the cabinets in the medication storage room. 365598 Page 8 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

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** 4. Observation on 09/15/22 at 8:01 A.M. revealed Aide #100 in Resident #26's room, who was on droplet isolation precautions. Aide #100 was observed to remove her gloves and wash her hands. Aide #100 proceeded to remove her isolation gown and discard the isolation gown in the trash can in Resident #26's room. Aide #100 did not perform hand hygiene after removing her isolation gown or prior to leaving Resident #26's room. Residents Affected - Many Interview on 09/15/22 at 8:20 A.M. with Aide #100 confirmed she did not wash or sanitize her hands after removing her isolation gown in Resident #26's room and/or prior to leaving Resident #26's room. 5. Observation on 09/14/22 at 8:56 A.M. revealed Housekeeping Aide #63 entered Residents #9, #13, #30, #34 and #35's room's with door signage reading Special Droplet Contact Precautions - all healthcare personnel must wear N95 or higher-level respirator mask before entering the room and remove after exiting. Housekeeping Aide #63 was wearing a surgical mask and was not wearing a N95 respirator when she entered the rooms of Residents #9, #13, #30, #34 and #35. Interview on 09/14/22 at 9:00 A.M., with Housekeeping Aide #63 verified she was wearing a surgical mask upon entering the rooms of Residents #9, #13, #30, #34 and #35 which were designated as under Special Droplet Contact Precautions. She stated she knew she was to wear a N95 respirator but could not breath well when wearing an N95 respirator. Interview on 09/14/22 at 10:59 A.M., with Infection Control Preventionist Nurse Licensed Practical Nurse #51, verified Housekeeper Aide #63 should have been wearing an N95 respirator upon entering the rooms of Residents #9, #13, #30, #34 and #35. Based on medical record review, observation, and staff interview, the facility failed to practice proper infection control during resident care, failed to perform hand hygiene appropriately, and failed to wear appropriate personal protective equipment in resident rooms under transmission-based precautions. This affected nine residents (#9, #13, #26, #30, #34, #35, #36, #38, and #176) and had the potential to affect all 74 residents. The facility census was 74. Findings include: 1. Observation on 09/13/22 from 7:59 A.M. to 8:27 A.M. revealed Registered Nurse (RN) #67 assessed Resident #38's blood pressure and did not sanitize the blood pressure wrist cuff prior to entering another resident room and using the same wrist cuff to assess Resident #176's blood pressure. During an interview on 09/13/22 at 8:27 A.M., RN #67 stated she normally did not sterilize her equipment between residents although she knew she was was supposed to. RN #67 stated she had disinfecant wipes on her cart which she was supposed to use. 2. Review of the medical record of Resident #176 revealed an admission date of 08/31/22. Resident #176 transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included but were not limited to pneumonia, acquired absence of part of lung, malignant neoplasm of prostate, and type two diabetes mellitus. Review of Resident #176's medical record revealed Resident #176 had a physician order, dated 365598 Page 9 of 10 365598 09/19/2022 Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449

F 0880 08/31/22, for Contact and Droplet Isolation (Transmission Based Precautions) related to COVID-19. Level of Harm - Minimal harm or potential for actual harm Observation on 09/13/22 at 8:33 A.M. revealed RN #67 entered Resident #176's room without donning an isolation gown and gloves, administered medications to Resident #176, and did not perform hand hygiene prior to leaving the room. Residents Affected - Many During an interview on 09/13/22 at 8:36 A.M., RN #67 verified she did not don appropriate personal protective equipment (PPE) including an isolation gown and gloves prior to entering Resident #176's room and did not wash her hands before leaving the room. RN #176 stated she did not know why Resident #176 was on precautions but she thought he had just returned from the hospital. 3. Review of the medical record of Resident #36 revealed Resident #36 was admitted to the facility on [DATE] with medical diagnoses including cerebral infarction, attention to tracheostomy, chronic respiratory failure with hypoxia, and hemiplegia and hemiparesis. Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment, dated 08/24/22, revealed Resident #36 had severe cognitive impairment. Further review of the MDS revealed Resident #36 received tracheostomy care and suctioning. Observation on 09/14/22 at 10:26 A.M. revealed RN #67 and RN #120 donned an isolation gown and gloves in order to complete trach care/change for Resident #36. RN #67 organized supplies on the bedside table. RN #67 and RN #120 used hand sanitizer prior to donning gloves. RN #67 left to get additional supplies (normal saline) and removed her isolation gown and gloves. RN #120 removed mucous from around the trach, removed her gloves, and donned clean gloves. RN #120 did not perform hand hygiene between glove changes. At 10:35 A.M., RN #67 returned with supplies and donned a new isolation gown and gloves. RN #67 opened a trach kit using sterile technique and added normal saline to the peroxide. RN #67 donned gloves to clean around the trach and upper chest. RN #67 doffed the gloves and donned new gloves but did not perform hand hygiene prior to donning the new gloves. RN #67 then cleaned the mucous from Resident #36's trach, doffed her gloves, and donned sterile gloves without performing hand hygiene prior to donning the new gloves. RN #67 provided Resident #36 with deep suctioning via the trach. Continuous suction was completed two times and the trach tube was suctioned and cleaned with water. RN #67 suctioned Resident #36 twice and asked Resident #36 if she felt she needed additional suctioning however Resident #36 denied the need for additional suctioning. RN #120 removed Resident #36's inner cannula. RN #67 doffed sterile gloves after suctioning and applied a new set of sterile gloves without performing hand hygiene. RN #67 was still wearing her isolation gown and proceeded to wash her hands with soap and water after removing Resident #36's trach. RN #67 then asked Resident #36 if she was alright and handed Resident #36 her ear buds upon request. RN #67 removed her isolation gown and placed it in the trash, then bent down and picked up dirty gloves off the floor and placed them in the trash liner, and proceeded to leave the room without performing hand hygiene. During an interview on 09/14/22 at 10:35 A.M., RN #120 verified she did not sanitize her hands appropriately during Resident #36's trach care/change and stated there were no alcohol-based hand sanitizer dispensers in resident rooms and they were only in the hallway. During an interview on 09/14/22 at 10:53 A.M., RN #67 verified she did not perform hand hygiene between dirty and clean procedures while performing trach care/change for Resident #36. RN #67 verified she did not perform hand hygiene prior to leaving Resident #36's room after she doffed her isolation gown and picked up dirty gloves off the floor. 365598 Page 10 of 10